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A fairer future for social care?

By Tom Dening


Social care remains high on the political agenda as the Commission on Funding of Care and Support has this week presented its report to the Chancellor and to the Secretary of State for Health. The Commission comprised the commendably small number of three members – Andrew Dilnot, an economist and Principal of St Hugh’s College, Oxford; Dame Jo Williams, Chair of the Care Quality Commission; and Lord Norman Warner, former Health Minister and erstwhile head of Kent Social Services. In their report, Fairer Care Funding, the Commission has proposed major changes to the current system.

There are two main proposals: that the threshold for council-funded support for home help or care home places should rise from the current £23 250 to £100 000, and that there should be a cap on the total lifetime amount charged for receiving care of about £35 000. Against this, there would be a charge of £7-10 000 per annum for receiving food and hotel services in residential care.

At present, paying for long term care in old age is the source of enormous worry to older people and to their families. There is a lottery as to whether an elderly person succumbs to an acute illness or whether they have a long term condition, such as dementia, which may require care over a period of several years. As a result, individuals are concerned as to whether they will be able to pass on any of the inheritance they have built up to their descendants or whether the money will all be spent in paying for care homes fees. Pressures around these issues may make people decline care that they really need or delay a move into a care home that could augment their quality of life – we should remember that being in one’s own home at all costs can be a lonely experience if you are immobile and housebound, dependent on the visits of carers even to use your own toilet for example, and even with three or four visits a day, you can still spend over 20 hours a day with no human contact at all.

Looked at another way, most risks that we face throughout our lives can be insured against in some way. Apart from, that is, getting old and frail. In which case, there is at present virtually no limit to the financial risk imposed by the need for care. The only ends are death or a fall of your assets to £23 000, at which point your council tax funded local authority will start to offer some help. It seems contrary to the spirit of natural justice that the group within society who are exposed to this risk are those towards the end of their lives who perhaps most merit our help and protection.

Dilnot, therefore, is addressing some of these questions. We have been in this direction before. The was a Royal Commission about ten years ago, which failed to agree on the solution, the main report proposing free care and a minority report proposing a level of charging for basic care. Scotland adopted the free care option, with mixed reports of the success and affordability of this solution. From south of the Border there are suspicions that England must be subsidising the system (along with free NHS prescriptions, free University places and so on), and there is in any case doubt as to whether this approach is sustainable without placing severe limits on access to care. England has been administering a system that everyone seems to detest and where everyone seems to think that change is necessary.

A potential criticism of Dilnot is that his proposals will subsidise wealthy home owners and enable them to keep more wealth within their families, thereby perpetuating social divisions. I don’t think this is really the case. My impression is that people with serious amounts of wealth are able to pay for care from their current income, for example renting out vacant houses or else paying for live-in carers, so that they never go anywhere near shedding their capital assets. In contrast, virtually anyone who owns their own house, be it ever so humble, falls above the current local authority threshold – so the closer you are to the threshold, the more likely you are to have to sell your (modest) home in paying for care. Therefore, it seems to me that the people who will gain most from Dilnot are not going to be obvious Tory voters. It isn’t just a case of the rich being subsidised here.

The cost? A mere £1.7 billion at today’s prices but this will rise with increasing numbers for at least the next 20 years. The Government may try to ignore these findings but the point is that the current situation is unacceptable and unjust. It won’t simply go away. One wonders whether there is scope for a social compact that ties care funding in with pension reform, and maybe that would make it an interesting deal for everyone.

Tom Dening studied Medicine at Newcastle University and trained in Psychiatry in Cambridge and Oxford. Since 1991 he has been Consultant Psychiatrist in Old Age Psychiatry in Cambridge. From 1999 to 2002 he was seconded part-time to the Department of Health as a Senior Professional Adviser, including work on the National Service Framework for Older People. He is now is the Medical Director of Cambridgeshire and Peterborough NHS Foundation Trust. He is the co-author (with Alisoun Milne) of Mental Health and Care Homes. He has previously written this post for OUPblog.

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