Adult Care: Please don’t complicate things further

The Commons’ Health and Local Government Select Committees got together to help Whitehall address one of its favourite areas for prevarication: namely what to do about adult social care.  Their joint Report, “Long-term funding of adult social care”, was published at the end of June but widely ignored by the media. The Minister, Caroline Dinenage, responded with an undated letter indicating they had nothing to say until their Green Paper appears this autumn.

The Report has six pages covering 33 conclusions and recommendations.  Nine key issues emerge:

1. Surprisingly, the shortfall is modest relative, say, to the NHS: “£2.2–£2.5bn.” in 2019–20. (para. 20). But far more funding will be needed in future. (paras.73 and 88).

2. Care should be available for all adults, not just the elderly. (para 38). Also surprisingly, about half the adult care budget goes on those of working age.

3. We should aspire “over time towards universal access to personal care free at the point of delivery.” (para. 42) But “accommodation costs should continue to be paid on a means-tested basis.” Needless to say, the Citizens’ Assembly (big focus groups) favoured “free at the point of delivery”. Furthermore, the need for personal care now should be extended to include “preventative” social care. (para 77).

4. “Risk pooling—protecting people from catastrophic costs, and protecting a greater portion of their savings and assets.” (para. 44). This is widely agreed in principle but no one has yet found a viable solution. This Report trails a few ideas but comes to no conclusion.

5. “People are generally willing to contribute more [in taxes] to pay for social care if they can be assured that the money will be spent on this purpose.” (para. 46 and 93-95). This assertion is fallacious as the TaxPayers Alliance has demonstrated. “Earmarking”, as hypothecation is called here, is not acceptable to HM Treasury but it does seem to work, in the form of insurance, in Germany.   

6. The cared-for should be able, as in Germany, to elect to receive cash to distribute to carers rather than the funding going to the caring organisations. State-funded caring should be extended to voluntary, usually family, carers.  The cost of this is not quantified. (para. 78).

7. Paras 89-91 make suggestions as to how local authorities can develop new income streams to provide plenty of money for social care and everything else.

8. At the national level too, the Report’s proposals would make things more complicated: “Much of our evidence suggested the need for national revenue raising options to be considered alongside, or instead of, existing or reformed local government funding arrangements. Given the scale of the funding challenge facing social care, many submissions also argued that a combination of different revenue-raising options will need to be employed.” (para. 84)  Some may regard these local and national money trees as optimistic.

9. “Given the interdependencies between the provision of health care, social care, and also public health, we recommend that in its discussions of future funding settlements the Government should consider all these in the round.” (paras. 100 - 107). “The concept of a cross-party parliamentary commission currently has the support of more than 100 MPs from all English political parties.” (paras 119-132).

This last conclusion is really the most important. Whatever the Green Paper will say, the debate will degenerate into party politics and it will not include the NHS. Above all, we need a non-partisan, intelligent analysis of health and care provision, taken together, balanced against what we can afford.

Good as this Report is in a number of respects there are three major concerns:

1. Armies of carers will be needed to cope with the much wider, but undefined, provision of care recommended by this Report, e.g. all age groups, preventative, free at the point of delivery. Given today’s staff shortages, low pay and unemployment, and reducing immigration, the Report should have addressed how many are needed. That said, there are ten times more people employed in the NHS than in adult social care, so switching resources from the former to the latter is worthy of consideration. And the Department of Health and Social Care has not published any strategy on the topic since 2009.

2. Add to those new carers at higher pay rates, the proposal to pay voluntary (family) carers. How many elderly couples now get along only because one cares for the other?  The Report does consider financial sources but, somewhat naively, accepts the Citizens’ Assembly view that people will happily pay more provided it is earmarked. The UK, with 23 different kinds of tax already, is at a 50 year high level of taxation. As the TaxPayers Alliance has demonstrated, when citizens say they’d be happy to pay, they mean for others to pay. The TPA demonstration took the form of asking passers by to put a ball in the “yes” box if they agreed that they should pay more tax or put the ball in the “no” box otherwise. Those putting their balls in the “yes” box were then offered mobile phones connected to HMRC so that they could increase their contribution immediately. None did.

3. Whilst the Report makes interesting suggestions for increasing the funds available from local authorities, it would be much simpler to abolish the involvement of the Ministry of Housing, Communities and Local Government, which plays no part in social care, and put funding with policy in the Department for Health and Social Care.  The Department for Education pays for schools so why shouldn’t the Department for Social Care pay for social care? Sharing those costs with local authorities is complex, would it be better to pick up the whole bill unimpeded by the ‘Office for Health and Care Sustainability’ recommended by the House of Lords? That would make the necessary interchanges with NHS England far simpler. Furthermore, the individuals’ contributions to their own care costs would need to be consistent across England and therefore set by the DHSC.

In conclusion, this Report further complicates what is already a very complicated matter.  It hits the nail on the head when it says: “Given the interdependencies between the provision of health care, social care, and also public health, we recommend that in its discussions of future funding settlements the Government should consider all these in the round” (para. 107), i.e. the DHSC should do what its title suggests.