Options for the future of adult social care: Shaping the Future of Care Together

Much of what the adult care green paper proposes is already  established. What is different is the concept of a National Care Service. Mark Ivory examines the detail while, on page 28, social care experts give their views on the funding options

The new green paper, Shaping the Future of Care Together, will be make or break for social care. It could eventually lead to a universal, rights-based system on an equal footing with the NHS or, despite the green paper’s ambitious rhetoric, it could result in little change to social care’s reputation as the Cinderella service. As the Conservatives’ claim that the document is “long on options and short on costs and conclusions” implies, this is the greenest of green papers.

Much depends on which of three funding options wins public approval during the consultation (see p28) and the outcome of the general election, which must be held by next June. Health secretary Andy Burnham is keen to publish concrete plans in a white paper before then, although implementation will inevitably rely on the goodwill of what seems likely to be a Tory government.

But strong public support for properly funded social care, unlikely though it seems in the current economic climate, would at least give a chance to the vision set out in the green paper.

In many respects this vision is simply existing policy in progress: preventive, joined up, personalised services underpinned by public information and advice are already established in name if not always in practice. The emphasis is on enabling users to live as independently as possible with a choice of support tailored to individual needs and aspirations. What is new is that the green paper repackages these policies as part of a National Care Service, which reaches out to self-funders as well as users now publicly funded in England and is intended to ensure consistent services linked to clear rights and entitlements (see panel, facing page).

National Care Service masterstroke

Counsel and Care chief executive Stephen Burke sees it as the government’s “masterstroke”, overcoming public ignorance of social care by giving it clear branding and raising its status. “Creating a National Care Service is ambitious and it could put social care on a par with the NHS,” he says. “Making care a universal service that everyone has a stake in and everyone benefits from would certainly make a big difference.”

But the question of whether the NCS would be much more than a national brand for local services is left unanswered in the green paper. Local authorities will continue to assess needs, and commission and provide services, although some fear that the NCS could concentrate too much power in central government. One option canvassed in the paper is that the government, rather than councils, would decide how much money individual users should get.

The Local Government Association says it rejects any attempt to “nationalise” social care in this way, claiming it would create less responsive services and hamper joined-up working. The LGA wants the alternative option, a part-national, part-local system under which people would be entitled to have their needs met but the local authority would decide how much money to give them. “A fully national system could undermine councils’ flexibility in commissioning and designing care services around the needs of the user,” says David Rogers, chair of the LGA’s community well-being board.

At the heart of the NCS would be a national assessment scheme, a “portable” assessment under which users would have the right to have their needs assessed in the same way everywhere and the right to have the same proportion of their care and support costs paid if they move elsewhere.

Eligibility hint

Social care minister Phil Hope hinted at the launch that care and support, at least partly covered by one of the funding options, might kick in when someone needed help with three or more activities of daily living. Comparisons with existing eligibility criteria are difficult to make, but this suggests that state-funded support might stretch down to those with “moderate” needs, a far cry from the current situation in which more than 70% of councils have set eligibility thresholds at “substantial” or “critical” needs.

“This green paper is a missed opportunity to raise capital thresholds and consider the immediate needs of people with modest means, who face the enormous cliff edge created by the means test,” says Richard Humphries, social care fellow at the King’s Fund think tank. “But the principles of the National Care Service are to be welcomed as a clear statement of what service users can expect from social care services. What is less clear is whether the NCS is just a statement of entitlements or whether it is an organisation in its own right. It looks like an organisation in the virtual sense, perhaps one that in effect franchises assessments of need out to local government.”

The dazzling prospect of equal status with the NHS is one thing, but it is a further question whether an NCS would address all the perceived unfairness across the health and social care divide. Although it promises to end the postcode lottery in eligibility for services, there is no guarantee that it will end the anomaly of the cancer sufferer whose personal care is provided free while the Alzheimer’s sufferer with identical needs has to pay because they are deemed not to have a “health” condition. Nor will national assessment criteria, by themselves, guarantee that everybody is assessed in the same way.

Jenny Owen, president of the Association of Directors of Adult Social Services, points to another parallel with the NHS. “You can have a national system of assessments but you’ve still got to apply it and it still has to be interpreted locally,” she says. “We have an example in the NHS, which is a national system that allows for many local differences.”

Elusive uniformity

The uniformity the green paper seeks may prove elusive, but social workers will have the consolation of knowing that individual professional judgement still counts. Owen sees advantages in national assessment built on the common assessment framework, a single assessment for all entitlements. “Less local flexibility may not be everyone’s cup of tea, but the consultation will tell us if the public thinks it worth trading that off for a system that they understand and is focused on their rights,” she says.

Whatever the public thinks, ultimately government will decide the fate of the green paper. The political consensus around long-term care which emerged a year ago has vanished as general election hostilities break out and there is a danger that the green paper itself will disappear in a cloud of dust.

For Gillian Crosby, director of the Centre for Policy on Ageing, this would be a failure of the vision the government has set out in its wider policy of building a society for all ages. “We mustn’t let the green paper become a political football because this is a debate that concerns all of us, not just those who happen to be older now,” she says. “People are running to their safe little bunkers and that’s not a good sign, but I want to be optimistic that the green paper will lead to a fairer, more transparent system.”

What we could expect

● Prevention services: Right to support to stay independent and well for as long as possible.

● National assessment: Right to have care needs assessed in the same way and have the same proportion of costs paid, wherever user lives.

● Joined-up service: Services will work together “smoothly”, particularly when needs are assessed.

● Information and advice: So that users can find their way through the care and support system easily.

● Personalised care and support: Services will be based on personal circumstances and need.

● Fair funding: Everyone who qualifies for care and support from the state will get some help meeting the cost of their needs.