The question of paying for the care of a rapidly ageing population has been simmering for some time but at some point is bound to become a critical issue for government and the public.
Politicians may be waking up to the fact that the number of people aged over 85 will grow by two-thirds over the next 20 years, compared with an average population growth of 10%. The problem is persuading the public of the seriousness of the issue.
That challenge is being taken up by a coalition of 15 organisations, launched last week, which is organising a series of seminars across the UK to address the question of how our future care needs will be funded, and the respective contributions of the state and individuals.
Gordon Lishman (pictured right), director general of Age Concern, one of the coalition members, sets out the challenge starkly: “Few people know at first hand the full extent of the chaos within long-term care.”
The coalition, Caring Choices, also includes the Local Government Association, the Association of Directors of Adult Social Services, Help the Aged, and research bodies the King’s Fund and the Joseph Rowntree Foundation. The latter two each produced large-scale reports on the future demand for long-term care last spring, from the fund’s Wanless review and the JRF’s Paying for Long-Term Care programme. These will form the evidence for the coalition’s campaign.
Both reports argued for the state to provide far more funding for long-term care in the future, alongside a new system of individual contributions to care which would put an end to means-testing (see Where are we now).
Following Derek Wanless’s report, published last March, the Department of Health set up a group to consider the long-term funding of social care, but its findings remain secret.
Meanwhile, funding pressures on councils have loomed large, with many tightening eligibility criteria for adult social care.
As a result social workers now have had the unenviable task of telling people in need that the state will not be paying for their long-term care. Ruth Cartwright, professional officer for England at the British Association of Social Workers, says performing this role “is an unfair burden on us”, adding that BASW, which was not invited to become part of the coalition, welcomes the debate.
She says: “People think care is free. We are having to go to panels pleading for an extra quarter of an hour of home care knowing that if this person gets a quarter of an hour, another person won’t get it. We really shouldn’t have to get into the business of rationing services. But that is the position we are in.”
Although Wanless criticised the government last week for its lack of progress on the issue, there is plenty of optimism in the coalition about the growing acceptance among ministers that it can no longer be neglected.
Julian Forder (pictured left), deputy director of the personal social services research unit at the London School of Economics, who worked on the review with Wanless, says the delay in government action is no bad thing. “It would not be wise for government to rush into these things. We have had the same system pretty much since 1948.”
Trish O’Flynn, policy officer for adults at the Local Government Association, says: “People in government and our organisation recognise that this is a growing issue. But the public at large are in denial. We need to open our eyes to what is coming. We need to think about this in terms of individuals, families, rather than a general mass.”
For Sue Collins, JRF’s principal policy manager and one of the authors of its long-term care research, there is a “head of steam building up” about the issue and it has “definitely been going up the government’s agenda” in the past two years. But she adds: “The missing bit of the jigsaw is what the public view is. That is one of the main things this coalition seeks to find out.”
Many of the bodies behind Caring Choices insist that as the population ages, the number of people who are not directly affected by the care needs of an older relative will shrink. All agree it is imperative that the public is engaged if more money is to be found for long-term care, with the options for funding care amounting to increasing taxes, taking public funding from other areas or increasing individual contributions.
But what is perhaps the most unpalatable area of the debate is what happens if people will not want to engage, the prospect of addressing what might happen when you are frail is simply too grim and distant a prospect to connect with?
As Mervyn Kohler, head of public affairs at Help the Aged, points out, although one in five people will require substantial care, four out of five of us will not. Where should the debate go from here? For Forder, we should consider what outcomes we wish to achieve and work backwards, an approach pursued by the Wanless review.
He says: “So often in the past, funding has been tinkered with in incremental ways, driven by cost pressures but not outcomes. We need to talk about what we want and how much money do we have and get the two to meet in the middle. You can’t have one without the other.”
Where are we now (back)Funding for the future
Derek Wanless proposed that the current means-tested system for care be scrapped and replaced by a “partnership model” in which the state would fund two-thirds of the cost of a personal care package for anyone in need. Above this, it should match fund contributions from individual service users up to the full cost. In its report, the JRF advocated an 80/20 split, costing the state an extra £2bn a year.
The state of play
The funding issue was first addressed in earnest in 1999, when the Royal Commission on Long Term Care for the Elderly recommended that personal care should be provided free. The proposal has been taken up in Scotland while England and Wales continue to use a means-tested system.
These are paid by the NHS to residential care users who are ineligible for continuing care, but require nursing care. In England users are either paid £139 , £87 or £40 a week, depending on their level of need. In Wales, a flat rate of £114.90 per week is paid and in Scotland £65.
In England, anyone with capital exceeding £21,500 must fund their entire package (minus any nursing fees). Those with savings below £13,000 get all costs paid by councils. Those in between have to part-fund care.
The same system operates in Wales, but with higher thresholds of £17,250 and £22,000. In Scotland personal care is provided to all at a rate of £145 per week. Other costs are means-tested with a lower limit of £12,500 and upper limit of £20,750. In each case, users must contribute all of their income, including benefits, save for £20.45 a week in England and Scotland, and £20.88 in Wales, which are kept as expenses.
In England, most councils use a means-tested system based on national guidance which states people should not be left with a disposable income of less than £150 per week, after charges. In Wales many councils do not charge, while in Scotland personal care costs are met and others means-tested.
This is a system of NHS-funded care that applies across the UK to people who have serious long-term health conditions. These people have their entire care costs met by the NHS. An average nursing home place in 2005-6, cost £433 a week for an older person. Recipients lose entitlement to attendance and disability living allowance and their state pension and income-related benefits are cut after 52 weeks.
Carer’s ViewSheila Bersin, 76, from Harewood in Knowsley, Merseyside, who cares for her 77-year-old husband, who has multiple needs, says:
“Who should pay for care is a very difficult question. No single model should not be imposed on us. There are people like myself and my husband who went without to bring our children up, and have saved for things like if the roof needed doing and that money can now affect whether we would pay for care or not. We can manage, and our council is very good, but many in our situation are not so lucky. I have always said that we want to stay at home for as long as possible, but I am starting to need help around the house which I will have to pay for. We are from a generation that went without.
We have grown up when rationing was still in place and we only had one egg a week. I know that we can’t get it right for our generation. What we are trying to do is get it right for future generations who don’t even realise what might be in store for them.”
Have your say
With an ageing population, how should care be funded? Should people contribute to the cost of their long-term care or should the state carry the cost? E-mail your views (no more than 250 word) to Clare Jerrom by Wednesday 9 May. The best response, as judged by the editor, will win an ipod.
This article appeared in the 3 May issue under the headline “Time to kick off a public debate”