The view on a clear day

Practitioners risk being submerged under the deluge of new policies, reports and suggestions for the future funding of long-term care. Pauline Thompson takes time out to assess what’s on the horizon.

As busy advisers dealing day to day with the problems raised by people within the current system of social care, it is difficult to keep track of changes, and it is a rare moment to be able to look at what might be happening in the longer term. But for those with a window, there is plenty on the horizon. There have been a plethora of new policy initiatives in health and social care. The main ones relating to social care, which affect older people, are found in:

Improving the Life Chances of Disabled People (Prime Minister’s Strategy Unit 2005);
Opportunity Age (Department for Work and Pensions 2005);
A Sure Start to Later Life – ending inequalities for older people (Social Exclusion Unit January 2006);
Our Health, Our Care, Our Say (Department of Health 2006);
A New Ambition for Old Age (Department of Health 2006).

Consistent themes are:

Better prevention services and earlier intervention, with more information for people to make healthier lifestyle choices and more support to maintain mental health and emotional well being;
More choice for people, both in terms of more convenient access to GP services and hospital care, and extending the availability of direct payments to groups currently excluded (mostly this will be to those who lack capacity), and the piloting of individual budgets;
Tackling inequalities and improving access to community services, by commissioners working together to address local inequalities;
More support to those with long-term needs, with people being supported to manage their conditions better and developing assistive technologies to manage in their own homes, and with an integrated health and social-care plan and integrated records;
Dignity in all care settings, rooting out age discrimination and ensuring the human rights of older people are central to the delivery of care – a very welcome emphasis, found in the most recent report A New Ambition for Old Age.

A new office, The Office of Disability Issues, has also been set up within the DWP (which includes disabled older people) and is currently developing a business case for investment in independent living.

Going local
A number of initiatives are already being piloted to achieve the above goals. There will be practice-based commissioning with GPs having more responsibility for local health budgets. Primary care practices will control the bulk of the local health budgets. The ‘payment by results’ tariffs, which are being developed for all providers of NHS work, will be refined in order to encourage promotion of health and investment in preventative services.

There will be more joint commissioning by PCTs and social care, and streamlined budgets and planning cycles based on an outcomes-based performance framework. Already from October 2006, PCTs have been reorganised to have much greater co-terminosity with local authorities.

By 2008 all local authorities with social-services responsibilities will have to appoint a Director of Adult Services (DASS). It is a post with strategic responsibility for planning, commissioning and delivering services for all adult client groups. It can be a joint appointment with the NHS but must be based within the local authority. Legislation is planned to ensure councils include adult social care in the portfolio of one executive member and it will be left to local discretion to decide the precise scope of the remit of this member.

Local Area Agreements which have this year been rolled out across the country are seen as the key mechanism for joint planning and delivery of services. In a report published in May by the Lyons Inquiry into local government it was suggested ‘that local government should be given greater freedom to ‘place-shape’ – where local government takes responsibility for the well-being of an area and the people who live there, promoting their interests and their future’. There would be fewer and better focused targets.

Going individual
There are two developments to give people more choice and control over their care services. First, it is intended that legislation will be changed to extend direct payments to people who currently cannot receive them (mainly people who lack the capacity to manage the payments or who have mental-health problems).

Second, the government is proposing individual budgets. These will bring together separate funds from a variety of agencies, and individuals will then have a single transparent sum allocated to them in their name and held on their behalf. They are currently being piloted in 12 different sites and at present the funds that can be accessed for individual budgets are – access to work, the independent living fund, disabled facilities grants, supporting people funds, community equipment and social-services home-care funding. The individual can then choose to use this money either as cash or for the provision of services. It is hoped it will stimulate the care market to provide what people want. Eventually other income streams will be included in the individual budget. It is not intended to extend this to health care. There will still be charges although it is not known how these will work given the different charging regimes attached to each of the funding streams. Reports from the pilot areas suggest that this is one of the most difficult challenges to overcome.

As part of their work, the office of disability issues is identifying the support, advocacy and brokerage services necessary to enable independent living for disabled people, to develop a business plan for delivery and funding of these services.

It is expected that individual budgets will radically transform the current way that services are provided with many more people employing their own personal assistants supported by ‘care navigators’ or brokers to help them navigate the system.

Another new initiative currently being piloted in 11 areas is self-assessment. It could involve people choosing to complete the assessment via the internet or with help from a local ‘third sector’ provider rather than social services.

It is planned to promote ‘social enterprise’ to provide high-quality services including voluntary organisations and value-driven organisations such as co-operatives – provision by these groups could include NHS services. There will be a fund from April 2007 to provide advice to social entrepreneurs to develop new models to deliver health and social care.

A move to more prevention
A major theme in all the policy documents is that services have become too targeted on those in the most need and that there should be more concentration on helping older people to remain in good health and providing services that will increase their well-being. These are seen across the board to include housing, fear of crime, befriending and handy person schemes; basically, a joined-up approach across the locality to reduce the needs for specialist services by making universal community services more accessible.

There are currently 19 pilot Partnership for Older People Projects (POPPs), which are specifically looking at demonstrating improved outcomes by providing more low-level care and support in the community. They are testing innovative ways of creating a shift in resources and culture, to incentivise greater investment in prevention.

In relation to health, it is proposed to develop an NHS ‘life check’ service to help people assess their own risk of ill health, based on an online self assessment, and with online advice and other support available.

The future of funding and paying for care
Any adviser who works with older people reading the above, might well be forgiven for wondering how this is all going to come about. When faced on a daily basis with services being cut, eligibility being tightened to ‘critical’, increased block booking of care beds limiting choice, and funding crises in both PCTs and social services with older people caught in the middle, the proposed vision does not so much seem a step change as a giant leap for mankind.

At the moment bids are being worked up by departments for the next Comprehensive Spending Review 2007, which will set spending until 2011. All the information suggests that it is likely to be tight, and not much more money will be forthcoming. Although Our Health, Our Care, Our Say recognises the need to ‘make specific resources available’ to fund some of the initiatives, it is stressed that it is more about better partnership working and achieving better value for money from existing resources. Yet the recent report from the King’s Fund (The Wanless Report), although looking at the longer term, suggested that an extra £3bn is needed now for a level of social care that achieves economically justifiable levels of personal care and safety.

In the longer term, recent reports on the future funding of long-term care have all pressed for a national debate about where the split should lie between the state’s contribution and what the individual is expected to pay. There is general criticism of the current system being unfair and complex.

Looking to the future
Since the Royal Commission’s report in 1999, With respect to old age, which led to some tinkering at the edges of the funding and charging regimes, there has been a reluctance on the part of government to engage in any further serious thinking about how care will be funded in the future, and how the costs will be divided between the individual and the state. But the number of people in the UK aged 65 and over is set to increase by 79 per cent between 2002 and 2041 while those aged 85 or more are set to increase in number by over 190 per cent. As a result, the number of people requiring significant support in later life will increase substantially (both in absolute numbers and as a proportion of the population) over the next few decades. The numbers of functionally disabled people in England are projected to rise from approximately 2.3 million in 2002 to approximately 4.6 million in 2041, an increase of 98 per cent. This is not something the government or the population can just ignore.

Yet this appears to be exactly what is happening. A recent survey of ‘baby boomers’ by Help the Aged, asked a sample of 942 people between the age of 45 and 65 whether they had planned ahead and how the costs of their care needs might be met in the future. Of these, 62 per cent had not made any plans, with some 20 per cent saying ‘life was too short’ to think about care needs. The same survey found that 65 per cent would be happy to pay more tax if it meant more care was available for older people. This accords with focus-group research undertaken on behalf of Age Concern, where there was a recognition that higher taxes or some sort of compulsory savings were needed to avoid problems in the future.

The subject has been given a new impetus with two reports following in quick succession.

Co-payments
The report of the King’s Fund ‘Wanless Inquiry’ Securing Good Care For Older People, (March 2006) contains a huge amount of detailed research and economic data about the current system and projected future need. It put forward as its preferred model a partnership proposal for funding. There would be a minimum guaranteed level of care, free at the point of delivery – set at 66 per cent of a total ‘benchmark’ care package, with the individual and state matching payments up to this limit. The ‘benchmark’ was set at a level that is described as being economically justifiable. Beyond the benchmark level of care, the individual would pay for themselves. The total extra costs of this proposal came to £1.7bn per year (but this included changes to Attendance Allowance so that two thirds of the budget spent of Attendance Allowance would offset the costs). It did not propose any changes to continuing NHS healthcare but pointed out that it throws up anomalies.

The Joseph Rowntree Report Foundations suggested a similar split whereby the state met 80 per cent of care costs with 20 per cent co-payment. This was costed at £2bn per year. The JRF report also suggested some interim changes:

Either transforming Attendance Allowance into a care allowance, or means-testing/taxing it;
Piloting a national public voluntary equity-release scheme to cover the private costs of home-based care;
Doubling the capital limits to £42,000 and reducing the tariff income to reflect income that can
be earned on deposit;
Doubling the personal expenses allowance for home-care residents;
Requiring all care-home residents to pay for the non-care element of their fees, subject to a means-tested local authority support (in effect getting rid of continuing NHS healthcare) using the savings to subsidise personal care.

Although the government is still ‘considering’ the reports, there are indications that there is a growing political awareness that the current system is not sustainable in the long term, and long-term decisions will have to be made.

Whether this government ‘bites the bullet’ so soon after the pensions debate has yet to be seen. The voting power of older people is growing. More and more middle-aged children have grappled with the complex system and end up seeing their parents paying for care that is often mediocre, and having to provide top-ups to get an acceptable standard of care, or paying higher fees as a self payer subsidising local authority funded residents, and they are angry. Inevitably there will be trade offs to be made, but this should be decided in an open transparent manner, with everyone having the opportunity to take part in a debate that is about all our futures.

Whatever happens it looks like we are about to enter some very interesting times. There will be new systems to deal with, and it is likely that some of the proposals will require new legislation. There are likely to be tensions between national and local accountability, and risk taking and protection. Advisers will need to watch this space!

Pauline Thomson is a policy adviser at Age Concern, England. She can be contacted at pauline.thompson@ace.org.uk