The debate surrounding the future of older people’s care

National Pensioners Convention, Walkden House, 10 Melton Street, NW1 2EJ

Foreword by Dave Prentis

UNISON’s health members are nurses, student nurses, midwives, health visitors, healthcare assistants, paramedics, cleaners, porters, catering staff, medical secretaries, clerical and admin staff and scientific and technical staff and we have a “Duty of Care” handbook to enable our members to be the guardians of safe effective health and care services.

We therefore welcome this pamphlet and the National Pensioner Convention’s (NPC) FAIR CARE CAMPAIGN  with its timely emphasis on a national Dignity Code that upholds the human rights and personal dignity of elderly people.

UNISON’s own recent research shows that social care has been characterised by continuous underfunding and a lack of the political will to solve this crisis and reach a consensus to implement a long term sustainable funding settlement. The effects on social care services are now reaching breaking point with an estimated 800,000 elderly people not receiving the care they need.

There is a consensus now for urgent reform and the promised Spring 2012 Social Care White Paper could provide us with a step in the right direction to meet the funding crisis if it includes the Dilnot Commission’s recommendations to allow a social care cap of up to £35,000 for each person in a nursing home with the remaining £1.7bn, rising to £3.4bn, funded through taxation such as National Insurance.

However the Dilnot Commission’s proposals do not go far enough in securing sustainable public care services. Charging those with assets of £100,000 (including the value of their home) and not charging those on means-tested pension credit continues the two-tier standard of care, and there is a fear that after the individual’s payment runs out, the government may not fund the extra care provision.

 Introduction

Social care covers all the services provided in the community which aim to help people overcome difficulties related to physical, mental, environmental or lifestyle problems. The aim of social care must be to ensure that people are able to live safely and satisfy their personal care needs whilst also enabling them to maintain their independence, dignity and inclusion in the wider society.[1]

However,  over the last few years it has become widely accepted that the existing social care system suffers from a number of inherent problems; namely its complexity, the unfairness of means-testing, a postcode lottery of funding and standards, little support for family carers and a distinct lack of personalised services. In addition there are concerns surrounding the standards and quality of care services, the training, remuneration and employment conditions of the care workforce and the lack of a robust and effective regulation and monitoring of care providers. Successive governments have also argued that changing demographics and an ageing population are putting the services under even greater strain. The system is therefore in urgent need of reform.

On coming to power, the Coalition government said it would address these concerns and appointed a Commission on the Future Funding of Care inEngland, chaired by the economist Andrew Dilnot. However, the Commission’s terms of reference and approach did not allow it to look at any of the well known problems associated with the care system; focussing instead on the largely single issue of funding. The Commission issued its report in July 2011, and it is the government’s stated intention to produce a White Paper in Spring 2012.

The Dilnot Commission reported that the current system of care is not fit for purpose, but unsurprisingly it was not the first to do so. Over a decade earlier in 1999 the Royal Commission on Long Term Care set up by the Labour government issued a critical report and called for free personal care to be paid for through general taxation, but the then Prime Minister, Tony Blair, refused to back the proposal.

Since then, over the last 13 years there have been 18 further commissions and other inquiries into various aspects of health and social care provision, including equality and human rights, eligibility, registration of providers and how care is to be paid for, and all of them have been critical of the care system. However, whilst the various reports have gathered dust, countless numbers of frail elderly people continue to suffer abuse, neglect and a breach of their human rights.[2]

At the heart of the problem facing the care system, is the false separation by successive governments of medical care funded by the NHS through taxation and social care that is provided largely by local authorities in the community and is means-tested. As a result of this conscious decision, thousands of frail elderly people with complex health problems have been removed from receiving free NHS medical care and moved into the community – either in their own home or in a residential home – to receive social care.

This has led to the perverse situation where those suffering from Alzheimer’s disease are classed as needing social care rather than medical treatment, and left to fund themselves.

Yet every time there is a consultation process on government proposals, we are asked not to let our judgement be clouded by past and current systems, but to look afresh at the problems. We are informed that the current system of social care is not working, but there is no analysis of this “current system” and how it emerged. Governments talk about their new vision, but they do not tell us what happened to the old one.

To add insult to injury, successive governments, despite acknowledging that the current system is not fit for purpose and delivering a “wish list” of the quality of care which frail elderly people should receive, have concentrated on privatising health and care services, reducing regulation and considering how social care could be funded without adding any costs to the state. However, given the growing importance of this issue, it is only correct that we begin discussing how much it would cost society as a whole to provide everyone in need with good quality, personalised, social care.

The purpose of this pamphlet therefore is to look at the social care system in the light of developments over the last three decades, to explain our call for a free National Care Service paid for through general taxation, to show why this is necessary and how it is possible.

The birth of the Welfare State

At the end of WWll the majority voted against the prospect of a continuation of the unequal society in which millions were denied health and social care because they couldn’t afford it. War weary people, who had suffered unemployment in the 1930s wanted a society to be responsible, caring, co-operative and democratic. The welfare state was a big step towards these principles of collective responsibility:

  • Publicly owned services.
  • Rights not charity.
  • Taxes and social insurance collected according to income.
  • Good services, including health and care, delivered equally and based on need.

These principles are the yardstick against which to measure a progressive society, and even today all the political parties include a paragraph in their election manifestos which acknowledge that in a civilized society old people must be treated with dignity and respect.

However, successive governments have undermined and are destroying the welfare state and it is with this understanding that we must look at the current catastrophic situation facing frail elderly and disabled people and their families in the health and care system.

We are told by some “experts” that social care has always been the responsibility of the individual and their family – and that it has never been the responsibility of the National Health Service.

Formally speaking this is true.

  • The free NHS was established to deal with illness and provide  care free at the point of delivery.
  • The National Assistance Act 1948 set out in broad terms the responsibilities of local authorities to provide residential accommodation for persons who by reason of age or infirmity were in need of care and attention. This responsibility stretched into home care services as well and now includes assistance to those who need some help to stay active and independent, i.e. sheltered housing, home helps, day centres, meals-on-wheels, luncheon clubs, drop-in centres. However, these services carry charges and users are means-tested.

Most people did not consider that affordable payments for these services were unreasonable. However, over the last 30 years there has been a systematic attempt to redefine illnesses affecting old age as “social” rather than “medical”; resulting in older people’s care being largely dealt with in the community. In doing so, not only has the issue of funding shifted from the “free” NHS to the means-tested individual, it has also meant that hundreds of hard-pressed and inadequate social services departments are now called upon to deal with the complex health problems of many frail elderly people.

Effectively, successive governments have turned the clock back – first, to the pre-WWII situation making local authorities, instead of the NHS, responsible for the care of the chronic sick and aged, then handing them over to cheaper private companies, means-testing the individual and their family and introducing “personal budgets” as a further way of reducing costs, restricting access to services and undermining the welfare state.

Changes in NHS care of elderly sick patients

With the establishment of the NHS and Regional Hospital Boards in 1948 came the development of geriatric medicine. NHS geriatricians developed the basic principles of the care of elderly sick and dependent patients. In other words the long term illnesses of old people were only separated from the medical conditions of other generations by the development of specialist geriatric departments within the NHS.

Professor Peter Millard, Emeritus Professor of Geriatrics,St. George’s Hospital,University of London, explained: “Rather than bed rest and ‘warehousing’, excellence in the medical and nursing management of these patients changed the focus to the development of purpose-designed and equipped wards to assess, diagnose, and treat them – there were out-patient clinics, rehabilitation, day hospitals, and respite beds for holiday admissions.

“Geriatric medicine had ten beds per thousand of people over 65 and 50 per cent of beds in district general hospitals. ‘Slow-stream’ treatment meant that gradually a trickle of discharges became a flood as potential long-stay patients were enabled to manage at home and hospital beds were freed for others to use.

“That was the situation from 1948 to 1981. Then policy changed. The number of beds was reduced to eight per thousand for those over 65, with only 3 per cent in district general hospitals and a critical number of NHS services were transferred to local authorities.” [3]

Over time geriatric medicine and departments have been cut and in some cases have disappeared. Very few nurses have the training to care for frail elderly patients or patients with dementia and the result is often catastrophic. Patients are in general wards and there are reports of situations of great concern when they cannot reach their food, cannot communicate to explain their pain and recent cases show that they often go without water.

Dr. David Oliver, a senior lecturer in elderly care medicine at Reading University and a member of the British Geriatric Society explained: “As doctors we are taught to deduce the medical reason behind an individual’s loss of function, yet in the case of the elderly this is simply not done. Instead, the diagnosis is just that they are old. . . when we think about problems in the health service we focus on issues such as dirty wards or MRSA, but the lack of attention to providing the right diagnosis and treatment for problems of old age is just as big a scandal.”

He said: “Government policy initiatives are also partly to blame – research funding and targets must be shifted towards illnesses that affect the elderly rather than what might appeal to voters, or what is seen as glamorous.

“Take osteoporosis, for example: one in two women will suffer an osteoporothic fracture in the course of their lifetime, yet fewer than half of women with the condition ever receive an assessment after a fall. It’s the same with Alzheimer’s. The disease affects 700,000 people in the UK, but only £11 is spent per person every year on research, compared with £289 for each cancer patient.” [4]

Dr. Anne Corbett, Research Manager of the Alzheimer’s Society commented favourably on recent research carried out in Bavaria which found that people enrolled on a 12-month regime of behavioural and mental exercises showed a postponement of the progression of the symptoms of dementia. She said that good care involves activities which people with dementia find interesting and enjoyable, and enables interaction with others.[5] However, public sector cuts and a reduction in the number of occupational therapists severely limit such care.

Severe strain on local authorities

Over time, the boundary between health and social care has shifted and those who would have been cared for in NHS long stay wards, with treatment aimed at a gradual return of confidence and wellbeing, are now in the community.

In 1990, the Conservative government’s Community Care Act (implemented in 1993) required local authorities to purchase nursing home care for people with “long term illness” – a move which started the process of shunting sick elderly patients out of the NHS often to vegetate and die in nursing homes.

In 2000 the Labour government announced the NHS Plan. This was the first time there was an agreement to pool the resources of social services and the NHS; new Care Trusts were set up to commission health and social care in a single organisation. It was a step further in transferring elderly patients from the NHS into local authority care. The Plan said that a single organisation would “help to prevent patients – particularly old people – falling in the cracks between the two services or being left in hospital when they could be safely in their own home”.

However, the Plan was explicit in stating that whilst medical care could be given free in nursing homes, in most cases it was social care that was being provided. A £900m package was also made available “for intermediate care services to allow older people to live more independent lives”; by effectively removing them from NHS treatment. Whereas the old NHS geriatric departments assisted elderly patients to return to independence through physiotherapy and other rehabilitative treatments; suddenly many of those requiring such treatment in the community or in nursing homes were being means-tested and having to pay for physiotherapy as an added-extra.

The transfer of thousands of chronically sick elderly people from the NHS to local authority care has created a severe strain on those services traditionally seen as social care. Gradually, and now more quickly with the Coalition government’s public sector cuts, local authorities remove sheltered housing wardens and close day centres, drop-in centres, luncheon clubs and meals-on-wheels services or increase the cost so that many have now stopped these services. At the end of 2011, the shadow care minister, Liz Kendall claimed that the cost of meals-on-wheels over the last year had increased by 13 per cent and elderly/disabled transport by 33 per cent.

The “knock-on” effect of these cuts, which also include services which keep people physically and socially active, e.g. swimming pools, leisure centres, libraries and adult education, is often isolation, depression and neglect – creating even more strain on critical care services and higher costs.

In the 1980s, local authorities cut their in-house services; so-called “best-value” contracts meant they opted for private agencies which put in cheaper bids to provide care; and as frail elderly patients are moved out of the NHS, care workers are called upon to carry out many procedures which in the past would have been the responsibility of trained nurses. This situation has been made worse as experienced, unionized local authority social services staff have been made “redundant” and their work handed over to private agencies employing under-trained and unqualified staff, on low wages and without proper terms and conditions of service.

The real cost of social care

Social care is that which takes place in the community and can be either domiciliary or residential; with different rules for each across the UK. For example, in England each local authority can decide whether it charges for care at home, and if so, how much, whereas in Scotland domiciliary care is provided free to over 65s, but individuals still have to pay for services such as cleaning, visits to day care centres and meals on wheels.

In England the rules have given rise to a post code lottery of social care costs in different parts of the country; with the highest spending local authority (Tower Hamlets) spending five times as much per older resident as the lowest spending council (Cornwall). Nevertheless, recent reports show that the average cost of home care is around £7,000 a year for 10 hours a week (approximately £13.50 an hour or £135 a week).[6]

However, the Fairer Charging guidance states that no charges should reduce the individual’s income below a certain level. This is currently the level of Pension Credit Guarantee plus 25 per cent — £171.69 pre-April 2012 figures. In effect this means that those with capital above £23,250 (excluding any property) will be expected to pay  the full costs, whilst those below will be means-tested and liable to a proportion of the charge.

For residential care, the rules are slightly different. In Scotland for example individuals receive a flat-rate non-means tested payment of £156 a week for personal care and £71 a week for any nursing care. Individuals still have to pay for their accommodation costs if they have capital of more than £22,750 and only receive free care if they have less than £14,000. However, those who do receive a personal care payment lose their Attendance Allowance (roughly half the award).

In England those with assets of over £23,250 (including the value of any property) will have to pay all their care costs, those with incomes below this will pay a proportion and anyone with capital of less than £14,250 will have the charges met by their local authority. In England, the average bill for a year’s care in a nursing home is around £36,000. [7]

In 2003, the Fair Access to Care Services (FACS) guidelines were introduced as a response to the outcry against the “postcode lottery” which allowed local authorities to use different criteria for assessing an individual’s need for care. The guidelines state that every local authority in England must use four standard criteria: critical, substantial moderate and low to assess and deliver social care, but all the evidence shows that most councils now only help people with substantial or critical needs, some of which previously would have been regarded as medical care provided by the NHS, leaving many needing help to fend for themselves or rely on friends and family for support.

As a result, hundreds of thousands of households are currently denied the help they need, whilst rising charges for those still receiving care in their own homes are forcing older people to reduce or even stop their support services.

A National Coalition on Charging report [8] in 2008 revealed that:

  • 80% of people surveyed who no longer use care services say charges contributed to their decision to stop their support.
  • 29% of respondents did not feel their essential expenditure (related to impairment/health condition) was taken into account in financial assessments to pay charges, meaning they have to choose between essential support and equally essential food, heating or utility bills.
  • nearly three quarters (72%) of people surveyed believe the government should think about the charges people pay for support at home in any plans to reform adult social care.
  • a fifth (22%) of people surveyed who currently use support suggested they would stop if charges increased further.

Research by the King’s Fund shows that the number of older people who need significant care support, but receive no assistance will reach almost 900,000 in 2012, rising to one million by 2015.[9]

The Royal College of Nursing (RCN) has also claimed that the rationing of support to those with the most critical care needs has created a “revolving door”, as older people who have unmet care needs are forced to go to hospital, placing the NHS under greater strain. Nurses also say they are frustrated that when older people are admitted to hospital, for instance after suffering a fall, they are only able to give them “wash and go” treatment rather than being able to ensure they are eating well and able to live independently. [10]

In addition, under the 2003 Delayed Discharges Act local authorities are fined £125 a day for keeping an older person in hospital after the time he/she is deemed fit for discharge. This legislation almost forces older people back out into the community, often without a suitable support package in place in their own home so that they are either quickly re-admitted or are unable to cope and are fast-tracked into a nursing home.

Given the government’s cuts to local government funding, and the lack of ring-fencing for adult services, the rationing of services is set to increase. Research suggests that at least 250,000 older people could lose their home care as a result.[11] Of these older people, 100,000 are projected to go without any support at all, while the remainder would be expected to buy support privately. There would be a 23 per cent rise in unmet need, when measured in hours of personal care required but not provided (either by paid or informal carers) and as a result there would be a 25 per cent rise in hours of personal care provided by informal carers.

As a result of such rationing, those with low and moderate needs have no choice but to either rely on voluntary organisations or family members to help, or do without. Naturally, this situation can lead to a worsening of their condition and their needs may eventually reach a substantial or critical level. The cost of providing this extreme level of care is therefore more expensive in the long term than would have been the case with earlier intervention, when needs were at a lower level. Any solution must therefore be for the long-term.

However, what is extremely worrying is that because the social care system has long been the Cinderella service of the welfare state, it has encouraged low expectations from those who it is supposed to support. Many individuals have modest desires about what help they might get when entering the system. Many feel they are receiving less support than they need – or are trying to muddle through without any help or guidance.

The exclusion of lower bands of eligibility means that people have particular difficulty in getting support with practical – yet vitally important – tasks such as housework, gardening and shopping. The National Pensioners Convention’s own research has found the care gap can include a lack of help with cooking, gardening, housework, visiting day centres, going out, shopping, DIY/maintenance, adaptations to property (ramps, showers etc) and bathing.[12]

Ultimately, the burden created by this care gap is felt by the individual’s family and carers. Despite a commitment from the previous government to ‘valuing’ carers through a Carers’ Strategy which is due to come into force by 2018, there is no suggestion from the Coalition of changing the current rules on the carer’s allowance which prevents someone in receipt of a state pension from claiming. Many support services, such as respite care, are also unavailable to existing carers.  As a result, the constant pressure of looking after a highly dependent individual, without the necessary support and help can lead to passive neglect, because carers are simply no longer able to cope.

Making the individual responsible

In January 2006 the Labour government issued a White Paper entitled “Our Health, Our Care, Our Say” with the aim of “a radical and sustained shift in the way services are delivered”. Whilst it was portrayed as a way of giving power to individuals to determine their own personalised care, in effect it has turned into a way of reducing services and encouraging greater privatisation.

Under the Conditional Resource Enhancement Scheme (CRE) known as Direct Payments/Personal Budgets, those receiving local authority funded domiciliary social care have an assessment of their individual care needs. This assessment calculates the number of hours and type of support they require and this support is converted into the £s required to deliver it. Money is then handed over to the individual in the form of a Personal Budget to spend as they choose.

However, the introduction of individual budgets raises a number of serious concerns. Many budget holders will be met with a bewildering choice of care providers, consisting of local authority services, private companies and the voluntary sector. The individual will therefore need to be directed to the “experts” offering advice and services and will inevitably be drawn into the growing market where private companies, the voluntary sector and charities compete for contracts to supply such services. As a result, the organisation offering “advice” may be the same one that is also providing a service. This therefore raises serious concerns relating to impartiality and independence.

Research also shows the negative physical and psychological effects that the responsibility of managing individual budgets can have on older people. The IBSEN Individual Budget Pilots Evaluation report October 2008 showed that service outcomes for those using an individual budget in the pilot were not improved for older people, and that their psychological well-being was damaged.

However, despite this obvious drawback for older people, the government seems intent on promoting individual budgets as the only mechanism through which care services can be accessed. This ‘cash for care’ model has shown that some local authorities are now refusing to offer a choice of how services can be accessed – with access to care being limited through direct payments only. The principle that all service users should have an individual budget in order to receive a minimal service is therefore inappropriate, especially as most frail older people simply want a decent service arranged for them that meets their needs.

Furthermore, under a national care system with proper assessment and funding, individual budgets would of course be completely unnecessary for delivering personalised care. Ultimately individual budgets transfer risk and responsibility either to the individual who needs social care or to their relative(s). They must now take on management tasks or deal directly with the private companies which will provide their advice or care for profit. However, there is no clear guidance for the individual when becoming an employer.

Fundamentally, expecting some of our most vulnerable older people to take on the responsibility of micro-employers – recruiting, dealing with payroll matters, contracts, discipline, employment rights, paying tax and national insurance – is simply unrealistic. In effect, rather than giving choice, individual budgets open up opportunities for abuse by those who manage the individual’s affairs and those organisations who see it as a chance to win contracts and make profits. Already evidence is emerging around the country that private agencies are offering to manage budgets for an average cost of 10-15 per cent; which in most cases will be paid out of the money that should have been used on care. It should also be noted that at the moment, these brokers currently fall outside any regulatory framework.

In addition, individual budgets raise serious concerns about the safety and protection of vulnerable individuals who will be responsible for employing their own care workers, who as lone workers are at present also exempt from registration, regulation and inspection. The responsibility of individual budget holders for arranging suitable cover for staff absence due to sickness and maternity leave also adds to this concern.

Far from enabling a highly-skilled and motivated workforce, the model of provision that is actually emerging encourages low pay and poor conditions, and risks entrenching problems of inadequate recruitment, retention and career development.

Furthermore, shifting funding and responsibilities onto individuals undermines local authorities, local democracy and the role of the welfare state. The personalisation of care is becoming synonymous with reducing choice, increasing privatisation and allowing the growth of an unregulated care service.

Now the government plans to roll out personal health budgets (direct payments) in the NHS from October 2012. In an announcement on 4 October 2011, Health Minister Andrew Lansley said: “It will give tens of thousands of people who receive NHS Continuing Healthcare – those assessed to have complex health and care needs – more choice and control over their care.”

The Department of Health explained  —  “A personal health budget is an amount of money that is allocated to patients so that they can use it to meet their health and wellbeing needs in a way that best suits them”. [13]

However, research carried out by Pulse — the GPs journal — found that “government plans to give patients control of their own health budgets have failed spectacularly to get off the ground . . .Several pilot areas selected nearly a year ago are yet to recruit any patients, despite being promised hundreds of thousands of pounds each in funding. Where patients have been recruited, NHS managers claim each is requiring so much attention the scheme risks denying care to those who aren’t included.” [14]

Privatisation of social care

Social care has been operating as a market for many years, with large growth in private care homes starting in the 1980s. The Community Care reforms in the early 1990s acted as a further stimulus for the development of the market and now the estimated size of the care sector in the UKis £23bn.[15]

In addition, there are around 21,000 separate organisations delivering care (ranging from a small number of large national providers to thousands of micro providers). For example, 58 per cent of care establishments have no more than ten employees. [16] It is widely acknowledged that 80 per cent of all social care is now provided by the private and voluntary sector.

In September 2007, Stock Market Digital reported that private healthcare firm BUPA’s pre-tax profits rose to £166m during the six months to June 30 – up by 47 per cent. Chief Executive Val Gooding said: “We remain confident that BUPA has an attractive range of market opportunities.” However, are the aims and values of private business compatible with those of social care provision?

Almost 1m vulnerable people are being cared for either in residential homes or in their own homes by scores of companies that have been bought out and run by a handful of private equity companies “earning” hundreds of millions of pounds from local councils and the NHS. But asset strippers (equity companies, banks and the property market) play “Russian Roulette” with the lives of the people they are supposed to serve.

In 2011 we witnessed the scandalous Southern Cross affair. Southern Cross Healthcare was the largest independent care home operator with over 750 homes, and 31,000 residents. Before it was floated in 2006, Southern Cross was owned by US private equity group Blackstone, and over the last ten years it made large profits. But during these boom years it offloaded its assets to raise cash (known as sale and leaseback) by leasing its properties back from a management company. A downturn on the stock market, huge rents and declining fees from local authorities as the cuts began to bite, meant that Southern Cross had become unsustainable. Meanwhile, staff and residents faced an uncertain future. Ironically, Four Seasons Health Care – which itself has debts of £780m, has now taken over 140 of the former Southern Cross homes.

In December 2011, the Public Accounts Committee reported that the Department of Health (DoH) had failed to tackle the problem when it arose, and has still to make clear what will happen if another provider gets into financial difficulty. Margaret Hodge MP, the committee’s chair said the DoH was simply not “monitoring the financial health” of care providers. [17] Given that the government is intent on opening up the sector even more to the private companies, it is completely unacceptable that there is no mechanism for safeguarding the interests of our most frail and vulnerable care users.

Evidence shows that the widespread privatisation of the care sector over the last decade has been responsible for reducing the standards and quality of care received by older people in the community. A new National Care Service must therefore seek to return much of this provision to the public sector.

Monitoring and regulating care services

In recent years there has been a systematic weakening of the rules and regulations surrounding the provision of care services, but it is important to see how this has happened. In April 2004, the Commission for Social Care Inspection (CSCI) was set up arising from the Health and Social Care (Community Health and Standards) Act 2003.

In its report “The State of Social Care 2006-2007” published in January 2008, the CSCI revealed that “most councils now only help people with substantial or critical needs, leaving many needing help to fend for themselves or rely on friends and family for support.”

  • 75 per cent of local authorities do not provide the moderate and low criteria.
  • 160,000 households are denied help.
  • 1.2m men and 1.6m women over 50 are unpaid carers.

It could have been that the government didn’t like this report, for in 2009 the CSCI was disbanded. In its place came the Care Quality Commission (CQC), with a budget of £164m – 30 per cent lower than its predecessor and a reduced statutory role.  Crucially, the CQC does not perceive itself as an ‘improvement’ agency – but one which focuses on what has happened rather than why it has happened.

The Commission alerts care providers that something is wrong, but it is up to the provider to put it right before the inspectors return to check if anything has been done. These delays can often leave very vulnerable people in neglectful and abusive environments.

Its 900 inspectors are currently responsible for scrutinising 409 NHS trusts, 9,000 dental providers, along with18,000 care homes and thousands of care agencies. In 2012 it will also begin regulating around 8,000 GP practices – but there were no plans to increase its workforce or funding.

With a reduced budget and such a workload it should come as no surprise that in 2011 the CQC reduced inspections by 70 per cent – from 4,000 to 1,000. Add to this that there are no terms of reference for CQC inspections, that inspectors have very limited guidance on how to operate and it can be understood that there is less focus on establishments that were previously rated “poor” or “adequate” and more time spent registering new providers.

In its report into the CQC the Parliamentary Health Select Committee says there has been a ‘”distortion of priorities” by those in charge, which has not protected the best interests of those it was supposed to champion. [18] In fact, since 2009 the CQC has faced some very serious questions as to its role and effectiveness in monitoring and regulating health and social care services in England. Well documented criticisms include:

  • The time frames for improvement are misplaced, so that the most serious concerns are given the longest times in which to improve.
  • When deciding on compliance, the CQC is unable to declare a single hospital ward non-compliant without having to consider the position of the entire Trust. As a result, most hospitals are found to be compliant, even though aspects of its care do not meet the required standards.
  • The CQC has acknowledged that there have been inconsistencies in their approach to inspection and they plan to make changes, but at the moment this does not allow the public to see a genuine comparison between hospitals or other establishments that have been assessed.

The CQC requested a further £15m to overcome these concerns and in November 2011 the government announced that it would make a grant of two-thirds of this sum – a further £10m for 2012-13. But such knee-jerk reactions are not good enough and it remains the government’s stated objective in the consultation of “keeping the burden of regulation to a minimum”. This seems difficult to justify; vulnerable older patients require greater statutory protection, through proper regulation, rather than less.

The future funding of care

On 4 July 2011 the Dilnot Commission into the future funding of care published its report “Fairer Care Funding”. The government has said it will consider the recommendations and respond in Spring 2012, but at the moment it is unlikely that ministers will adopt the Dilnot proposals.  Media reports suggest that future Treasury spending reviews, election politics, and the time required for the private care insurance market to become established would mean that any real change is unlikely before 2025. [19]

Nevertheless, the White Paper will seek to address the following issues:

  • The government’s response to the Law Commission’s report on Adult Social Care, May 2011.
  • Quality and workforce (looking at standards and training);
  • Provider failure (considering what should happen if there is another Southern Cross-style debacle);
  • Overseeing the market (with 80% of providers in the private sector).
  • The development and provision of financial services;
  • The integration of services, such as the NHS and housing.

At the same time as the White Paper, there will also be a separate Progress Report on Funding Reform and the Dilnot Commission’s recommendations. This will not of course be legislation and at this stage it is unclear whether there will be further consultation on any proposals.

Whilst any long-term delay would be completely unacceptable, it is nevertheless important to understand the way in which the care debate is being framed, especially as the Commission was given very strict terms of reference to produce a plan that was in keeping with the government’s programme of austerity.

In its report, the Commission recommends:

  • Capping an individual’s contribution to their care costs at £35,000. The state would then pay additional care costs once the individual has met that cap.
  • Means-tested support for residential care to be available to those with assets/income worth between £14,250 and  £100,000 (currently £23,250) – including the value of any property. For those with assets worth £75,000 the cost of care  would be around £15,000. Those with less than  £14,250 would not have to pay.
  • Those in residential care to remain liable to pay for their food and accommodation costs – capped at a maximum of £10,000 per year. This would mean individuals paying up to £190 a week.
  • The Commission’s proposals are estimated to cost £1.7bn a year, rising to £3.4bn by 2026. The recommendations suggest that this money could be raised either through additional general taxation, re-allocation of existing government expenditure or using a specific tax, such as national insurance, on those aged 65 and over.
  • A new national assessment system would guarantee support to those with substantial needs or worse, but not anyone with moderate needs (including those requiring help getting in and out of bed). This assessment would be portable and continue to apply if a person moved from one borough to another.

However, it remains unclear how the Commission’s proposals relate to care at home. As mentioned previously, at present the value of property is not included in any assessment of assets when determining those eligible for home care, but the Commission is suggesting that this may need to change in the future.

The proposal to raise the threshold on assets to £100,000 would also do little to prevent older people from still having to sell their homes in order to pay for care, given that the median housing wealth for a single pensioner is £160,000. Dilnot’s proposals would have been fairer if the threshold was set somewhere above £500,000 so that tens of thousands of pensioners would be removed from ever having to pay for care.

Furthermore, since no more than a quarter of all over 65 year olds are likely to ever need more than the capped amount of £35,000 worth of nursing home care, it is questionable whether the state would ever step in to pay any additional costs. The Commission even states: “We see our proposals as a type of social insurance policy, with a significant ‘excess’ that people will need to fund themselves.”

Implementing the suggestion that additional funding for care could be found by making older people pay special national insurance would place an unacceptable burden on a single generation – rather than sharing the cost of care across society as a whole.

The care workforce

The care workforce currently accounts for 80 per cent of the total expenditure in social care, but inevitably affects 100 per cent of how individuals experience the service. Achieving a high quality care service is therefore intrinsically linked to the nature of the staff it employs.

In March 2009 the CSCI/CQC registered providers’ list showed that the private sector now operates 75 per cent of domiciliary care agencies. For residential care the figure is approximately 69 per cent. TV programmes such as Panorama, and evidence from trade unions operating in the care sector, show that the privatisation of much of social care across theUKhas led to poorer pay and conditions, a high turnover of staff and limited access to training or career development.

The result is that many private care providers do not deliver on the high standards of quality of care originally promised. Too often local authorities have awarded contracts for care to the lowest bidder (so called “Best Value”).  This race to the bottom has driven down, not only the terms and conditions of the workforce, but also the level, quality and standard of the care delivered.

Care assistants and home carers are recognized by the Low Pay Commission as among the lowest paid workers in the UK, with median pay rates in private agencies currently standing at just £6.30 an hour.[20] In practice even this figure can be lower when care workers are paid by the visit, rather than the hour.

A snapshot of qualifications in the domiciliary care sector for 2007 also showed that nearly three quarters of all staff were without any suitable qualification.[21] Out of 32,000 domiciliary staff employed just 0.9 per cent had a Level 4 or higher qualification, 3.9 per cent had achieved Level 3, 18.1 per cent Level 2 NVQ, 0.1 per cent Level 1, 5.7 per cent had other relevant qualifications and 70.7 per cent possessed no qualification at all. Evidence suggests that the same trend is also apparent in the residential care sector.

Often newly appointed care workers receive little more than instruction via a short film or “on the job” training – usually from equally inexperienced and unqualified colleagues. Yet these individuals are in the front line of caring for some of our most vulnerable older people; undertaking some of the most challenging work, in a highly pressurised environment.

Caring for vulnerable older people with diverse mental and physical needs is both a skilled occupation and one that carries a high level of responsibility. Care workers need to be able to detect the signs of dementia, and other illnesses, as well as having skills in personal care, first aid, health and safety, manual handling, food hygiene, communication and how to properly relate to those with mental and physical disabilities.

However, care workers often operate to tight schedules that do not allow the time necessary to support clients in self-care, or to establish the relationship that is the necessary foundation of a high quality personalised service and a key factor in job satisfaction. Travelling time between clients is often unpaid, which adds to the growing pressure on staff to reduce the time they spend with the client; also as a result of current cuts many councils are buying only 15 minutes of care for some clients. Many care workers are therefore forced into a position of being “shock absorbers” for the tensions within the system. While the quality of care is undermined in some cases, in others it is the commitment and kindness of the workers themselves that compensate for the system’s deficiencies at the expense of pushing them to do more and work longer than their contracted hours.

The sector also struggles with problems of recruitment and retention, and the shift to local authorities’ contracting out service provision means that employment is now predominantly with private sector agencies. Precarious employment relationships, such as pseudo self-employment and zero-hours’ contracts, are already common; casualisation of employment is likely to increase as the use of individual budgets and direct payments become more widespread.

An alternative vision of social care – A National Care Service

Politics is about choices. Where to direct public spending is informed by the prevailing issues of the day and the government’s particular priorities, but, despite numerous official inquiries and media investigations concluding that the social care system is not fit for purpose, our society has never really debated whether social care of the country’s older population is in need of greater funding, higher standards and better regulation. The public is never asked if it feels the system is working and how it might be put right. At the heart of the issue is funding – which affects quality and delivery of service, but there are also issues of dignity and respect which need addressing.

Fundamentally, society has to consider why the responsibility for funding the care of older people rests with the individual, rather than on society as a whole in the same way that the NHS, education and defence are financed. Of course there is the artificial divide between medical and social care and the urge to move older people out of hospitals and into the community as quickly as possible, but there is also the expansion of the hugely profitable private sector, whose aims are beginning to look incompatible with the needs of vulnerable pensioners. The answer must therefore lie in the creation of a public National Care Service, funded in the same way as the NHS, that can deliver high quality and comprehensive care that meets individual needs – either at home or in residential care.

Essential elements of a National Care Service should include:

  • National Assessment – nationally determined assessment used throughoutEnglandto assess care needs. Individuals should have the right to have their needs (critical, substantial,    moderate and low) assessed and receive the appropriate care from a universal menu of services. At the same time family carers’ needs must be assessed. Assessments would also be portable, and move with the individual should they leave their particular local authority area.
  • A Comprehensive Service – individuals and their family carers to be entitled to receive a variety of care services from a range of regulated providers of the highest standard. There should be no divide between health and social care provision and the process of accessing care should be transparent and easily understood. All services should operate to nationally agreed standards of pay, conditions and training properly regulated and enforced.
  • Information and advice – individuals and their carers to be able to easily access straightforward information and advice about their entitlements to services at every stage of their care, and advocacy when required. Whether in the community, care home or hospital, individuals and their family carers should be entitled to receive information which clearly explains their entitlements to care, how to access the services available and their rights as a service user.
  • Personalised care – a range of medical, care and support services to be made available, tailored to individual personal circumstances and needs, delivered by a regulated provider and based on holistic assessments carried out by medical and social care professionals in consultation with the individual.  Under a National Care Service there would be no need for personal budgets.
  • Respect and dignity – upholding the rights and maintaining the personal dignity of older people, within the context of ensuring the health, safety and well being of those who are increasingly less able to care for themselves or to properly conduct their affairs. There should be a Dignity Code  (see centre pages) which applies to all care providers and  recognises that certain practices and actions are unacceptable to older people.
  • Fair funding – society to share the cost of providing care for those in need. A tax-funded universal National Care Service should entitle individuals to free non-means-tested care, support and accommodation appropriate to their needs.

Future funding of care

The Wanless Social Care Review of 2006 [22] summarised the amount of money in circulation in the adult social care system as follows:

  • £8bn spent by local authorities (largely funded through central government grant).
  • £1.6bn recouped through means-tested charges on individual users.
  • £3.7bn paid through tax-funded disability benefits (Attendance  Allowance and care component of Disability Living Allowance).
  • £3bn spent by the NHS on the long-term care of older people;
  • £3.5bn spent privately in residential and nursing homes.

This gives an existing total spend on social care of £19.8bn including the NHS contribution. A more recent House of Commons Library calculation also showed that in 2011/12 total net expenditure on social care for the over 65s would be £7.4bn – very near the Wanless figure for the amount local authorities spend on social care. In addition, the Wanless report also suggested that the first two thirds of a person’s care package should be free of charge, and the final third would be means-tested based on their income.

In contrast, the NPC’s FAIR CARE CAMPAIGN  not only seeks to change the way social care is funded, but also addresses the issues of quality and standards. It calls for all care to be paid for through general taxation – rather than being means-tested, and in addition, it seeks to professionalize the social care sector with improved training, staff conditions and regulation.

As a step towards this, free domiciliary and residential care could be provided to all existing users at a cost of £5.1bn. But an improved National Care Service would have to also take account of the following unmet needs:

  • Provision of services for those who have low or moderate care needs and are currently excluded from the system.
  • Improved terms and conditions for care staff.
  • Modernisation programme of residential homes. [23]
  • Improved regulation and monitoring.

The total cost of such a social care system could therefore be estimated to be nearer an additional £10bn. If however, a comprehensive National Care Service was truly inclusive, there could be significant savings from other areas of care expenditure that could help to reduce the tax bill.

The choice we face as a society is to find the additional funding by diverting existing spending from one area to another, accepting the need to pay additional tax – or a combination of the two. For example, the combined cost of the Iraqand Afghanistanconflicts are estimated at £20bn,[24] £46bn of tax payers’ money was used to bail out the Royal Bank of Scotland during the economic crisis and £25bn is lost every year in tax avoidance, with a further £70bn evaded by large companies and wealthy individuals.[25]

In 2008, the HM Treasury Report detailed the effect of a 1p increase in income tax as follows:

  • 1p increase in the basic rate of income tax would raise £4.44bn.
  • 1p increase in the higher rate of income tax would raise £0.88bn.
  • Total raised £5.32bn.

Net funding for an improved National Care Service would therefore cost an additional £7bn – requiring an increase in income tax of less than 1.5p in the £1. For someone earning £25,000 a year, this would cost them £277 extra a year, i.e. around 75p a day.

Conclusion

What underlies the government’s vision for social care is the desire to reduce the role of the welfare state and the public sector, and encourage the private and voluntary sector to take over the role of providing as well as regulating and monitoring services. This raises some very serious concerns which, if not properly addressed, could add to the problems of a system that is already not fit for purpose and failing to meet the care needs of our most vulnerable older people and their families.

In addition, the role of in-house and public sector provision needs to be re-built and there should be a re-introduction of specialist geriatric wards with trained staff into hospitals. Publicly provided care homes and care services, based on high levels of training and workforce development could play an essential role in setting and maintaining standards and quality across the sector.

Reordering public spending priorities and addressing the need for increased taxation, diverting money from private health care provision would provide sufficient resources for a twenty-first century social care system that meets national standards and is available to everyone, based on their care needs, rather than their income.

If there is any doubt as to why urgent reform is needed, a recent case study makes it clear.

Elisabeth Loe’s late father, Albert Thompson, was diagnosed with vascular dementia in 2005. The former aircraft engineer wanted to stay in his own home and spent more than £160,000, his life savings, in four years on home care.

“Two carers were excellent, a lifeline for me, but all the others were terrible,” Mrs. Loe said. “My father would be regularly left soiled, unshaven and with food around his face and clothes. Some of the carers used his condition as an excuse to do nothing, saying he wouldn’t let them come near him, rather than coaxing and persuading him.”

Some carers could not speak English, others took home food bought for her father and others slept on duty. Mrs. Loe added: “Someone from the agency said to me: ‘We are a commercial organisation that happens to operate in the care sector.’ I think that says it all.” [26]

In 1997, the British Geriatrics Society produced a series of expectations and recommendations for the care of older people. Their proposals stated that health and care services should aim to:

“Enable older people to lead as full and independent a life as possible as active members of the community; provide comprehensive health and social services to support people in their own homes; ensure dignity is preserved and distress minimised at all times, ensure training and high professional standards are established and maintained by all staff.”[27]

This is an ideal for which we must now strive.

Private health company BUPA is currently offering health insurance for 98p a day, based on a 40 year old man, non-smoker, living in Oxford. Pensioners would of course be asked to pay considerably more, but it is unlikely they would gain much benefit from doing so as the scheme excludes any treatment associated with:

  • The ageing process
  • Any pre-existing conditions
  • The provision of physical aids or devices
  • Deafness
  • Problems with vision
  • Care in a nursing home, or
  • Chronic or long-term conditions.

By contrast, a National Care Service funded through taxation of around 75p  a day is a much better and more inclusive system.

FAIR CARE CAMPAIGN

The National Pensioners Convention officially launched the Fair Care Campaign on 20 March 2012. This calls for:

  • Creation of a National Care Service, alongside the NHS funded through general taxation and based on medical and personal care needs rather than ability to pay;
  • Holistic assessments to determine need to be carried out by medican and social care professionals in consultation with the individual;
  • Introduction of a UK-wide Dignity Code (see below) to uphold the rights and maintain the personal dignity of older people who are less able to care for themselves or to properly conduct their affairs;
  • Improved standards of care, through better monitoring and regulation and enhanced training and staff conditions;
  • Greater protection and specific legislation covering the issue of elder abuse;
  • A return of the majority of social care provision to the public sector.

Dignity Code

The purpose of this Dignity Code is to uphold the rights and maintain the personal dignity of older people, within the context of ensuring the health, safety and well being of those who are increasingly less able to care for themselves or to properly conduct their affairs.

This Code recognises that certain practices and actions are unacceptable to older people, such as:

  • Being abusive or disrespectful in any way, ignoring people or assuming they cannot do things for themselves
  • Treating older people as objects or speaking about them in their presence as if they were not there
  • Not respecting the need for privacy
  • Not informing older people of what is happening in a way that they can understand
  • Changing the older person’s environment without their permission
  • Intervening or performing care without consent
  • Using unnecessary medication or restraints
  • Failing to take care of an older person’s personal appearance
  • Not allowing older people to speak for themselves, either directly or through the use of a friend, relative or advocate
  • Refusing treatment on the grounds of age

This Code therefore calls for:

  • Respect for individuals to make up their own minds, and for their personal wishes as expressed in ‘living wills’, for implementation when they can no longer express themselves clearly
  • Respect for an individual’s habits, values, particular cultural background and any needs, linguistic or otherwise
  • The use of formal spoken terms of address, unless invited to do otherwise
  • Comfort, consideration, inclusion, participation, stimulation and a sense of purpose in all aspects of care
  • Care to be adapted to the needs of the individual
  • Support for the individual to maintain their hygiene and personal appearance
  • Respect for people’s homes, living space and privacy
  • Concerns to be dealt with thoroughly and the right to complain without fear of retribution
  • The provision of advocacy services where appropriate 

    [1] Briefing on Adult Social Care, GMB Congress, 2008

    [2] Close to Home, Equality and Human Rights Commission, November 2011

    [3] Uncovering the real care debate – Why we need a welfare state, NPC pamphlet, 2008

    [4] Interview with Dr David Oliver, Daily Mail 29 April 2009

    [5] Alzheimer’s Society website article, www.alzheimers.org.uk, 1 December 2011

    [6] Growing care crisis as charges for elderly home care top £7,000 a year, www.labour.org.uk, 29 December 2011

    [7] Cut the cost of nursing home care, Daily Telegraph, 7 June 2010

    [8] Charging into Poverty, National Centre for Independent Living, 78 June 2010

    [9] Securing good care for more people: Options for reform, Kings Fund, March 2010

    [10] RCN response to the Dilnot Care Commission, January 2011

    [11] Personal Social Services Research Unit, LSE and University of Kent for Age UK, 2010

    [12] Survey of social care users and providers, NPC, 2007

    [13] Personal Health Budgets, Department of Health Press Release, 5 October 2011

    [14] Patients shun personal budget pilots, Pulse, 17 November 2010

    [15] Oversight of  Social Care Market, Discussion Paper, Department of Health, October 2011

    [16] Briefing on Adult Social Care, GMB Congress, 2008

    [17] MPs fear rerun of crisis that led to collapse of Southern Cross, Guardian, 6 December 2011

    [18] Annual accountability hearing with the Care Quality Commission, Health Select Committee, September 2011

    [19] Delay on care reform until 2025, Daily Telegraph, 14 December 2011

    [20] Skills for Care, NMDS-SC, December 2008-February 2009

    [21] Skills for Care, NMDS-SC, November 2007

    [22] Securing Good Care for Older People, Wanless Social Care Review, Kings Fund, 2006

    [23] £540m according to Calculating the cost of efficient care homes, Joseph Rowntree Foundation, September 2008

    [24]Afghanistan andIraq have cost £20bn, Daily Telegraph, October 2011

    [25] There is an alternative: The case against cuts in public spending, PCS, 2010

    [26] The Times, 25 January 2011

    [27] Standards of Medical Care for Older People, British Geriatrics Society, February 1997

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