The Health and Social Care Bill currently in the House of Lords is intended to:
- sort out the under-funding of social care;
- remove the need for people to sell their houses to pay for their care;
- promote joined-up service delivery;
- replace the competitive model with a collaborative one.
Sadly, as I wrote here, it appears to be a quick fix component level response to a whole systems problem which will simply “kick the problem on for a few more years”. There is little point putting more and more money into the first aid camp at the bottom of the cliff without building a fence at the top.
The cap on the amount which can be spent on care home fees will favour the rich in that people who do not have sufficient savings will still have to sell their house to pay for their care.
The “Integrated Care Systems” and “Integrated Care Partnerships” will be very costly and appear more concerned with preserving:
- the current configuration of local authorities and NHS Trusts, and;
- the purchaser / provider split and commissioning;
than they do the provision of integrated care.
Successive Governments have tried to get health, social services, police, education and housing to work together, but none has grasped the nettle of different geographical areas, different funding streams and different lines of accountability, which have been the main impediments.
Since the 1990 National Health Service and Community Care Act the “contract culture” has led to:
- a “minding” rather than a “mending” service with social workers increasingly used to assess the eligibility to specific services rather than using relationship and therapeutic counselling to resolve problems;
- further fragmentation with different components of a “package of care” bought from different providers, and;
- “self-funders” (a dreadful term) being waived away denying them an “independent verification of their wishes” and their families the help and support they need.
There is a wealth of empirical evidence on the “social determinates of health” which have demonstrated the correlation between income and demand upon the NHS.
At just £7,430 (£9,698 with pension credit) Britain has one of the lowest State Pensions in the western world. The national living wage is £18,278 and average earnings £30,212. The definition of poverty is less than 60% of median household income.
There are two million older people living in poverty in Britain – many of whom, prior to the abolition of the “default” retirement age in 2012, were forced into retirement and condemned to spending the rest of their lives in poverty. As they retired before 2016 they are not entitled to the new State Pension. Rising food and fuel prices, being essential items, will hit the poor disproportionately.
Occupational pensions have been eroded and savings not kept pace with inflation.
80% of the expenditure of the NHS is on older people. The Netherlands with the highest state pension in Europe spends 60% of its health budget on older people.
An estimated 1.3million older people suffer from malnutrition costing the NHS £19.6billion per year. There are five main causes of malnutrition: lack of money; lack of motivation; incapacity; lack of support and social isolation. Therefore, if by increasing the state pension to lift older people out of poverty, together with the other changes, were to reduce malnutrition by 90% it would save £17.85billion. Given the correlation between income and demand upon the NHS there could be a further reduction in demand of between 10% and 15%.
What might the outcome have been had the Government used the £57.5b, it has already committed to health and social care, differently to pump prime radical reform based upon a “whole systems review” by:
- raising the State Pension to 60% of average earnings (3.8m older people live alone) or £18,127, which would still be lower than much of Europe and slightly less than the “living wage” to lift all older people out of poverty. There would be savings on pension credit (which only had a 60% take up), housing benefit (there would need to be some provision for the higher rents of London and the South-East – possibly with the addition of regional housing allowances), and the winter fuel allowance. And a minimum of 20% of this increased pension would be clawed back from people with other income through taxation.
- bringing all services together, on the old County Council areas, in-order to achieve shared geographical areas, funding streams and lines of accountability – returning health and police to local democratic scrutiny within central government direction and taking out a tier of local government, making collaboration easier and saving millions on management with greater public accountability.
- removing the purchaser / provider split and discontinuing specialist commissioning and replacing them with a statutory, voluntary, private sector partnership.
- Freeing up social workers to practice their skills in using relationship and various therapeutic techniques to resolve problems.
- making other requisite organisational, leadership and cultural change to:
-
- liberate professionals and organisations working directly with people from the “straight jacket” of the “contract culture” enabling them to respond in situ to changing need, innovate and develop;
- remove functional divisions along patient / client pathways by the creation of “whole task, right sized multidisciplinary teams” able to “plan, do and evaluate” their own work which completes the learning cycle of constant improvement;
- change from a “constraining management culture” to an “enabling leadership culture”, and;
- agree a strategy with the Trades Unions to end the use of agency staff to save money and ensure greater continuity of care.
- work with Housing Associations and the Private Sector to develop extra-care sheltered housing with nomination rights and a base for the “multi-disciplinary teams”
- ensure that all older people have a “verification of wishes” before being admitted to a care home;
- extend NI to all working people (as Government intend) with the State Pension only paid on retirement with phased arrangements – ie one day’s work – 4/5th
- the higher state pension would mean that people who do need long term care could pay more by handing over their income, less their personal allowance, up to the cost of the home as they do now and remove the need to take capital (savings or house) into account;
A more detailed costed article was published in the Municipal Journal on the 21st December which confirms that after initial up front pump priming this would be achievable at less cost than Government has already committed to health and social care. A win win.
* Chris Perry is a former Director of Social Services for South Glamorgan County Council, a former Director of Age Concern Hampshire, a former Non-Executive Director of the Winchester and Eastleigh Healthcare NHS Trust and a former presenter of an award-winning public affairs programme on Express FM.
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13 Comments
Even if the state pension were raised to £18,127 per year, this is still only around half the annual cost of long term residential care so even if this was all handed over towards payment of fees, there would still be a shortfall. I am unclear whether you are proposing that taxpayers should be paying for this shortfall or the individual until such time as their assets are down to a certain figure. It may seem hard to have to use up savings and wealth, including the equity in a home, to pay towards the cost of living in a residential home, but all taxpayers should not be paying extra to ensure that some people can benefit from inheriting property etc
Brad Barrows. Thank you for taking the time to respond Brad. If you read the longer article in the Municipal Journal you will see that this is taken into account in the costings. The Government proposes introducing a cap on how much can be paid, the additional contributions from the higher pension simply enables capital (savings and house) to be disregarded altogether.
The main savings are on bringing all services together to serve the same geographical areas, with common funding streams and lines of accountability, the reduced demand upon health and social care as a result of the higher pension and the other organisational and cultural changes proposed.
There is a lot of good intentioned talk around the pensions and social care problems but as someone who is not entirely tuned in to all the different remedies put forward to solve these perennial problems it might help to frame the solutions to these problems in a way that people who might benefit from the information could understand. I know it is probably my own lack of intellect but it would help to really understand the different remedies to sorting out this very serious issue. Also it does not escape my notice the number of times I have read over the years how the UK lags behind other nations in the amount paid to our pensioners? We are not in the desperate state many pensioners find themselves in but if we had to go into care even selling our home would not take care of the costs for long in my knowledge and understanding?? Thanks for raising this issue.
@Chris Perry
Thanks for the clarification. Basically, the proposal is to stick with the Tory Government plan of a cap on what individuals have to pay and instead require ordinary taxpayers, including many on relatively low wages with little wealth, to foot the bill so that inheritances can be protected. I believe the approach that should be adopted is that there should be a cap on the amount of savings/wealth that is protected from being used to pay residential care costs, and all other wealth, savings, assets should be used to pay the costs before asking taxpayers to step in. (I also thing personal care and nursing costs should be paid by the state but that additional social care and residential care costs should lie with the individual until their assets are reduced to the set figure.)
Brad Burrows. The Government’s proposal in the Health and Social Care Bill is to put a cap of £86,000 on what one can pay towards one’s social care costs. However, this will clearly benefit the rich as those without sufficient savings will still have to sell their house to pay for their care. By increasing the state pension, reducing the demand upon health and social care, and because older people would be able to pay more towards their care, whilst still retaining their personal allowance, it would be possible to disregard capital (both savings and house) and still save money on what the Government proposes.
@Chris Perry
“….average earnings £30,212”
Presumably you mean median earnings rather than mean earnings?
@nonconformistradical
It is also the median HOUSEHOLD disposable [1] income, not the median individual earnings:
https://www.ons.gov.uk/peoplepopulationandcommunity/personalandhouseholdfinances/incomeandwealth/bulletins/householddisposableincomeandinequality/financialyear2020
Average can signify (arithmetic) mean, median or mode, but in this case as the ONS makes clear, it is median.
[1] Disposable income is the amount of money that households have available for spending and saving after direct taxes (such as Income Tax, National Insurance and Council Tax) have been accounted for.
@Brad Barrows
I believe the approach that should be adopted is that there should be a cap on the amount of savings/wealth that is protected from being used to pay residential care costs, and all other wealth, savings, assets should be used to pay the costs before asking taxpayers to step in.
Sensible, I would add one caveat, the cap should be varied based on the number of dependents under the age of say 25.
So if no dependents, the full estate could be used, qualifying dependents could potentially get financial support to remain at school, study or become a nurse/carer…
Sorry ‘dependents’ should perhaps be named beneficaries. I was thinking of both the elderly and adults with younger families, who are forced into care.
This “whole systems review” was much broader than just how one pays, or charges for, long term care: which is costed in the appended article in the Municipal Journal. However, the cost of the Government’s proposed cap at £86,000 (which would favour the rich as those without sufficient savings would still have to sell their house) would be £5.4b. The cost of disregarding all capital (savings and house) at the end of these changes, given the higher pension, would be £3.1b.
All types of public service (police, fire, schools, health, social care etc) organised geographically, and run by a single unitary authority. Is that what Chris Perry means? Is this to be achieved, like action on climate change, in a few decades, gradually, with no pain to ANY vested interest, and starting in the next parliament? Or is there to be a BIG BANG, a date when it all happens, when the financial savings roll in? A day when the surplus public officials get the sack? (Surely their pay would be a large part of the savings.)
When is the happy day when a British Napoleon takes charge? She or he certainly isn’t any party leader at Westminster – nor in one of the 3 other Parliaments. Nobody had the guts even to implement the entirely feasible Dilnot Report!
Nothing good is going to happen until everybody pays a bit more tax, the wealthy pay a lot more, and there starts to be a redistribution of wealth.
I do wonder whether I aught to be a LibDem.
I worked in the Care sector for more than a few years I have suffered and endured so many Big New Ideas thst cause chaos and delay ongoing improvements that i lost count of them. (National and Local)
This (I have not read it fully) seems to be the basis for a Vision for the sector to aspire to that might just work. If only it can be approached on a ‘steady yet at reasonable pace’ approach based on continuous improvement it may be acheivable without the useual debilitating disruption of the Big New Idea. Good stuff.
Nursing care should remain in the NHS, free at the point of delivery and according to need. Incentives to take out insurance for residential care could include tax advantages, a certain exemption for those on benefits and varieties with compulsory take up of a minimum like car insurance. How much the state should contribute to this is a political question.