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National Care Service on the horizon…

27 June 2018

In a bold paper from the Joint Select committee on Health and Social Care and Housing, Communities and Local Government a new vision for social care has been borne (or resurrected – some might say). The timing of this report is crucial, particularly in light of the things it comes before – including the social care green paper, the NHS ten year plan – and crucially the Comprehensive Spending Review. As you read on, no doubt there will be the necessary recognition that the solutions proffered do not address the short term well recognised and well documented crisis, but as the rabbits of the March 2017 budget have shown, short term cash – whilst problematic – is not inconceivable to address – however ‘macho’ or not it is to ask for it! However, the committee was looking at long term funding – so I suspect they would say – noted – but not on our agenda…

The big ticket items in this report come thick and fast – and I will try and unpick these briefly. Firstly, and importantly the committee outlines six conditions by which future plans for both the delivery and funding of long term care.

Providing high quality care
  • Considering working age adults as well as older people
  • Ensuring fairness on the ‘who and how’ we pay for social care, including between the generations
  • Aspiring over time towards universal access to personal care free at the point of delivery
  • Risk pooling—protecting people from catastrophic costs, and protecting a greater portion of their savings and assets
  • ‘Earmarking’ of contributions to maintain public support

There is some synergy with the seven principles expressed by Jeremy Hunt in his speech earlier this year, but some radical departures which I will explore in more detail - including of course the key principle around the aspiration of a move towards free personal care – or in populist terms – the provision of a national care service. This idea, whilst not new, has gained significant recent interest. It did, of course, appear in the 2017 labour manifesto. It was also the subject of extensive government research and a white paper under the previous labour administration when Andy Burnham was the then Secretary of State for Health. It also has reappeared in the narrative around care under DevoManc – under the mayorship of Andy Burnham.

Some of the basic Dilnot principles remain, seen in the condition above around risk pooling. The ongoing assertion that people in residential care should retain responsibility for their accommodation costs, a key factor of determining what exactly gets measured as a contribution towards any future cap, raises some interesting possibilities. As we continue to wait for the government proposals around the provision of sheltered rent and that of long term accommodation, should we look once more at the proposition of recognising long term residential provision under the same umbrella as these models of housing? This model was explored in detail in a Commission on Residential Care produced by Demos in 2014 and supported by the NCF which provided options on how this could be achieved – definitely worth a dust off – if you are sitting in the green paper team. The means testing of accommodation costs could be addressed within the wider specialist and supported housing benefit system with the potential providing some much needed confidence in the provision of publicly funded residential care.

The notion of intergenerational fairness is of course, again, a current political hot potato. The recent reports by the Resolution Foundation of their Intergenerational Commission concluded the need for the government to address intergenerational fairness, which  perhaps gave confidence to the notion of framing the application of a hypothecated tax on the over 40’s to pay for a national care service within this umbrella. The challenge for any future application of this tax, is that it needs to be read alongside the other growing understanding of the potentially perilous financial future for large proportions of our older population as the long term sustainability of the pension system and its ability to cope with our admirable increases in longevity is drawn into question. The fairness of taxing someone potentially for up to 60 years of their ‘100 year life’, to pay for the existing model of a care system that they may only sporadically meet the eligibility criteria for, will fall at the first hurdle. Here is, I suspect, the real opportunity for the green paper, which will be able to describe a future funding system that will meet a future model of care that will be much more responsive, accessible and focussed on providing preventative care in a timely and responsive fashion. This radical future for social care could be exciting and visionary – and something that people would be prepared to buy into - on the promise that they would get the ‘world class’ quality of care that communities and people deserve. 

It is very important that the report recognises that the future funding system must consider both working age and older adults. Whilst the green paper announcements always recognised the need for a whole system approach around funding, the lack of visible activity in relation to working age adults has caused great concern. The explicit suggestion of the ‘over 40’s’ contribution towards funding the services for working age adults, as well as older services provides a strong link to the notion of universal provision supported by all – although in many ways undermines the notion that the tax is in some ways addressing ‘intergenerational fairness’. This is further challenged when we note the findings from the most recent ADASS budget report where those who expressed a concern about the overall pressure on social care budgets from either working age or older peoples services – 32% felt that pressure would come from working age adults, as oppose to 12% who felt would come from older people alone. This, alongside the propositions around inheritance tax, will I feel leave the committee proposals open to accusations around where the balance of responsibility should lie, in a way that the collective contribution towards public services made via the national insurance scheme is broadly understood. 

There is of course much more detail in the report – of particular interest the focus on business rates and government grants – but more on that another day. The report is peppered with acknowledgements that if you were going to design a system that met not only our future but also our current needs – you wouldn’t start here. However, I feel that the committee has had a good go at ‘clean sheetism’ and there is much value to be explored as we start the new chapter for social care – perhaps entitled ‘National Care Service – Open All Hours’.

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