The 30bn question

The Wanless report is brimming with ideas but it is the policymakers who, ultimately, will have to make it work – if the will is there, writes Jon Glasby

What a week it was for older people’s services. First, there was a critical report from the Audit Commission, the Healthcare Commission and the Commission for Social Care Inspection, highlighting the ongoing problem of discrimination and ageism.(1) Then, public sector strikes began over pensions. This was followed by the launch of the eagerly awaited Wanless report, exploring the future funding of older people’s services.(2)

While each attracted considerable media attention in that final week of March, few commentators seemed to pull all three together and consider what they had to say collectively about older people’s services.

Perhaps this is unsurprising given the bleak outlook: if you’re an older person now or in the future, you may receive high quality support, but you could also face poor services, chronic underfunding and a disaffected and alienated workforce.

By far the most significant of these three is the Wanless report, which looks at future services, levels of need and the best way of funding social care for older people. After influential reviews of health care and public health, Sir Derek Wanless has produced a similar approach to social care.

However, there is a fundamental difference: while the first two reviews were supported by the government, the Department of Health refused to back this work and social care seemed destined to be overlooked.

As a result, it is greatly to the credit of the King’s Fund (which funded the report) and Wanless that they have defied initial government opposition and delivered such a detailed and fundamental report. As the Wanless team points out, there is widespread dissatisfaction with the current funding system and little information as to whether the 13bn we spend on older people’s services delivers desired outcomes.

Although the main features of the Wanless report have been well rehearsed (see report’s key features, facing page), how will it be received and what impact might it have? First, the report is well argued and balances detailed economic analysis, accessible critique of the current system and pragmatic, long-term solutions. And, with a comprehensive spending review due in 2007, the report seems timely, and its findings are social care’s best hope for future funding.

What may matter more in the long-term is the context into which the report was launched. So far, official responses have been ambivalent, and the report has alternated between being seen as unnecessary, as an irritating distraction or as a welcome contribution to the debate. Now the Department of Health has announced its own working group (with Wanless as a member), and opinion is divided as to whether this is a genuine attempt to learn from Wanless’s report or a more cynical attempt to kick it into the long grass. However, with future spending likely to be tight and with the NHS already in financial crisis, future spending of about 30bn seems unlikely.

Also crucial are references in the report to prevention and well-being. Although we know something of the potential of social care to reduce hospital and care home admissions, we know a lot less about whether more general prevention works. While everyone believes that the current system – making people wait until they are in crisis before they qualify for support – is counterproductive, does investment in low-level prevention reduce the need for future services?

In many ways this is the 30bn question, and yet the answer is that we simply don’t know. To date, no government has had the conviction to develop and sustain a long-term preventive approach, and this way of working must remain a matter of faith. With prevention a central feature of the recent health and social care white paper, the evidence base remains worryingly thin and rectifying this has to be a priority.

Perhaps most difficult to predict is the “partnership model” itself. While this has several advantages, the report recognises that this remains different from the NHS, where care is provided free at the point of delivery. We have never had a proper national debate about what should be free to all citizens and what we should be expected to pay for, and this underlying issue is unlikely to go away.

Also worrying is the pensions debate – in one sense, an occupational pension is a partnership model with a minimum guarantee from the state and additional contributions paid by both the individual and their employer. At present, this is the subject of industrial action in the public sector – partly because of concerns about affordability and partly because of accusations that the rules were changed part-way through. Although pensions are slightly different in that contributions are paid over a long period, the similarities are sufficient to sound warning bells.

Moreover, pensions policy is almost impossible to understand, owing to the complex nature of the system and almost perpetual changes in policy and products. Trust is also at a low level, with suspicions and allegations about misinformation and mis-selling. If all this is the case for pensions, there may be important lessons for the future funding of social care. Over time, the main strength of a partnership model may well be its key weakness: because it is extremely flexible, it may be acceptable to policymakers in a way that free personal care would not. However, for the same reasons, it offers fewer long-term guarantees to people who use services or to those preparing for older age.

None of this is the fault of the Wanless team, which has produced what could turn out to be one of the most fundamental contributions to adult social care for decades. Yet whether policymakers pick it up and make it work remains to be seen.

In the longer term, more joined-up health and social care and a greater emphasis on prevention are both essential, but thinking through what this means and how to do it in practice is an urgent priority.

Report’s key features

  • Social care is underfunded with significant unmet need.
  • Three service models are considered for the future: current services, core business (changing the system so it achieves the highest level of personal care) and a well-being approach (which builds on core business but also delivers social inclusion and broader well-being).
  • Costs may range from 10bn in 2002 to 24bn, 29.5bn or 31.3bn in 2026, depending on which model is pursued.
  • There are many ways to fund social care, but the review favours a partnership model. Under this, the state would provide a minimum level of care free (perhaps 66 per cent of the total care package). After this, the state matches individual contributions pound for pound (with those on low incomes supported by the benefits system) up to agreed levels. Key advantages include an end to means-testing, greater value and greater sustainability.

    Jon Glasby is head of health and social care at the Health Services Management Centre, University of Birmingham, and a Social Care Institute for Excellence board member. He was also co-author of one of the Wanless appendices on Scottish free personal care.

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    The author has provided questions about this article to guide discussion in teams. These can be viewed at and individuals’ learning from the discussion can be registered on a free, password-protected training log held on the site. This is a service from Community Care for all GSCC-registered professionals.

    This article explores how the Wanless review’s findings are social care’s best hope for future funding and why policymakers need to pick it up and make it work.

    (1) Commission for Social Care Inspection, Audit Commission and the Healthcare Commission, Living Well in Later Life: A Review of Progress against the National Service Framework for Older People, Healthcare Commission, 2006
    (2) D Wanless, Securing Good Care for Older People: Taking a Long-term View, King’s Fund, 2006

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