Adult care green paper series: what provision should be paid for?

Much of the discussion on the reform of adult services is about funding, but first we need to work out what provision should be paid for, says Andrew Mickel, who also examines how the Germans model their adult care

In 1999 the Royal Commission on Long Term Care for the Elderly recommended that the state pay for all long-term personal care. That idea was rejected by the UK government, but nine years later, it has yet to be decided what the state should provide.

After years of lobbying government, most bodies aren’t under any illusions that the forthcoming green paper into long-term care and support of older people in England will announce that the state is going to start giving out gold-plated Motability scooters to all and sundry.

But the question does need to be answered if any progress on funding models for social care is to be made. If there is no agreement on what a social care service is to provide, it will be impossible to work out how to pay for it. In part, the debate comes down to what type of care should be provided. One option would be for the state to set a minimum standard of care for certain conditions or support needs – with payments dependent on recipients’ financial means – in an effort to end the postcode lottery. At the other end of the spectrum, it could be argued that the state should only fund care for those most in need.

In some areas, attempts have been made to overcome this by adopting a universal approach. In 2002, Scotland introduced free personal care for all. Northern Ireland is now considering it, and already provides free nursing care while some English local authorities, such as the Isle of Wight, provide free personal care for many over-80s.

More generous

However, Niall Dixon, chief executive of healthcare think tank the King’s Fund, says the Scottish model is problematic. “I don’t believe the Scottish example is free personal care. It moves in that direction in the sense that it is a more generous system than that in England. But it is a rationed system, where some councils have run out of money.

“I wouldn’t necessarily go down that route, which is almost pretending the state can do everything, when it can’t. I’d rather we had a straightforward system that looked at the role of the state, the individual and the family. We need the best way of devising a system that makes the most of what is already there, and recognising each of the contributions, and that the one complements the other.”

If there is to be a universal standard for care the debate would be able to move on to funding and some moves have already been made in that area. For example, Sir Derek Wanless’s report for the King’s Fund recommended the state and individual share the costs of care.


Lord Sutherland chaired the 1999 royal commission, and has since chaired the review into the Scottish model. “The real question is not how much cash, but where means testing is applied. Means testing in Scotland is applied to people going into residential care, and it’s for the living costs of that. I still think that’s a sound principle.”

But even taking the universal approach, the question remains as to what level of care individuals should be entitled to. One option being considered by Help the Aged is for an entitlement to a basic care home bed. Sutherland says there is little choice but for the state to start providing more residential care because all trends are pointing to a massive rise in cases of dementia in the expanding elderly population. “The line that is taken on dementia will inevitably affect everything else they do and can afford to do,” he says. “I know they’re doing a separate paper on that, but it should come within the national health guidelines. Ideally, stretching it, I would want to see the whole business of health and social care under one budget, so it doesn’t fall on only those who are over 65. If there is squeeze on budgets, it should have to be spread across the whole of health and social care.”

However, residential care is most commonly used by people in the final two or three years of their lives, so if the trend for elderly people living healthier lives continues, the focus will remain on home care. Working out what is going on with home care packages and who should pay what is more difficult because the current system cuts across several budgets with forms of means testing that vary.

So would cutting bureaucracy be a good enough reason to end means-testing, and have the state provide home care services for all? In the personalisation era, what the state should be paying for in home care is no longer a clear-cut question, as reforms in Germany have shown.

Glendinning on Germany

Caroline Glendinning is professor of social policy at the University of York. She is examining overseas social care reforms for the Department of Health. She says that means-testing in Germany was considered “highly demeaning” so reforms to remove it were popular. Instead, older German citizens now receive services up to a certain value at one of three fixed levels, according to their level of medical need.

But it is how users can receive the money that is really of note. “You can take it either in the form of entitlement to services or a cash payment. Cash is far more popular even though you get less – three-quarters of people entitled will opt for at least some of their entitlement as a cash payment. The assumption is the money is largely to pay for informal care from family or friends,” Glendinning adds.

In effect, such a system would reward informal care, while allowing more individualised services that better meet people’s needs. But it does come at a cost, says Glendinning. “In countries that have entirely cash-based systems, such as Austria, there’s been little investment in collective systems. So there is an important role for the state to continue to support the services people want to use, and assuring proper levels of quality.”

Removing means-testing would entitle even the rich to state cash. But that is a small price to pay, says Dixon, to ensure that those people just above the means-testing cut-off points do not end up out of pocket. Such a system could also end the postcode lottery while allowing local authorities to retain autonomy over social care.

Wider puzzle

However, even if the forthcoming green paper did start offering answers to these questions, it is only one part of a wider puzzle. What can be provided depends on what funding system is chosen. Pension and housing policies require reform to ensure that people can save assets for their own future. People need to be better informed of the need to save and what they will be expected to pay for. And benefits could be brought together more tightly with the social care system to ensure support continues for those with no assets.

None of this will happen quickly, so in the short and medium terms there will be those who need helping through the system. Paul Cann, director of policy at Help the Aged, says the government can use the green paper to start communicating with people now about how they can make their own arrangements. “My first step towards a long-term care settlement would be to put in place a comprehensive, quality system where people can pick up the phone and be helped through their care options,” he says. “This is cost-effective and I don’t know why government hasn’t moved into top gear and made this happen. The cost is tiny compared with a Wanless-style solution.

Click here for last week’s article on models of funding care

Published in the 16 October 2008 edition of Community Care under the headline ‘Do we have the means?’

Web links

 Royal Commission on Long Term Care for the Elderly

 The government’s Care, Support, Independence document

 Wanless report

Germany’s model

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