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Call for bloodletting after King's Fund tears into care service crisis The King's Fund's inquiry into care services for older people in London is a stark warning to the government that a system already beset by financial and organisational problems will be unable to cope unless it is radically overhauled.

The health care think-tank's report highlights a multitude of problems, including poor planning and the complexity of the care system. Although it points to some London-specific challenges, particularly the high proportion of older people living in poverty, poor health and inadequate housing, there is overwhelming support for the report's claim that it reflects a national trend.

The report contains four main criticisms of care services in London for older people: their "restricted" access to care and practical support; limited choice and control; the risk posed by "untrained and unqualified" staff; and hardship caused by inadequate funding and "controversy over who pays for long-term care".

To address these problems, the King's Fund wants the government to develop the market for care services and strengthen the power of older people as consumers. But it warns that the market is "immature". Many providers are "fragile" and funding pressures on the NHS and councils "frustrate" the development of services based on needs.

Martin Green, chief executive of the English Community Care Association, says market development is crucial to prevent the "crisis" in care for older people getting worse. But he says there needs to be "better quality and continuity" in the commissioning of services.

"Commissioning problems are legendary," he says. "Partly it's because of a lack of training and a lack of clarity about what they are doing. At the same time as local authorities and the government talk about delivering appropriate care packages, managers are buying services at the lowest price they can get.

"There needs to be some serious restructuring, reorganisation and reallocation of resources, and some blood on the carpet in social services departments."

Jonathan Ellis, policy manager for health and social care at Help the Aged, says cultural differences between health and social services departments are to blame for commissioning problems. "It's about a lack of understanding, of awareness and of how different parts of the system can work together," he says. "A lot of the barriers are imaginary."

The uptake of direct payments, which are intended to give service users more control over the care they receive, is particularly low in London, but very low in England as a whole, the report notes. The adult social care green paper, Independence, Well-being and Choice, talks of extending the use of direct payments to give older people more control, and there are calls for a radical rethink of the direct payments system to make this vision a reality.

But even if this were achieved, the money available to provide care for older people is inadequate and is often diverted to children and families services, the report finds. Social services directors admit that this continues to happen in some parts of London, and that their budgets are under constant pressure.

Public resources are only enough to help older people with the greatest needs, the report adds. And, as councils try to control costs, they subsidise lower fees for publicly funded service users with higher charges to self-funders.

There is also a lack of clarity about the circumstances in which older people are entitled to receive free NHS care and means-tested social care. A problem arises over local interpretation of the NHS criteria for funding continuing care, although the government is expected to set out national criteria this year.

Stephen Lowe, social care policy adviser at charity Age Concern, says, although funding for adult social care increased by 28 per cent from 2000 to 2003, older people's services benefited from only a 22 per cent rise.


A report due soon from the Social Policy Ageing Information Network, which counts Age Concern and Help the Aged as members, will show that money has been diverted to services for younger adults as well as children's services while the cost of providing care has risen "well above the rate of inflation".

It is hoped that the King's Fund will provide some solutions to these funding problems when Sir Derek Wanless completes the organisation's wider review of social care.

Lowe says Wanless's report will be crucial in justifying to the government the need for the 2007 comprehensive spending review to allocate more funds for older people's care.

He is cautiously optimistic, as is Ellis, who believes Wanless's report will have at least as much influence as his landmark report on health service funding published in 2002. And Stephen Burke, chief executive of charity Counsel and Care, says Wanless will provide the sector with the "ammunition" to make the case for more funding.

However, Ellis also warns that the proposals in the green paper for more preventive services will inevitably mean there will be a period when these run in tandem with the current system where "fire-fighting" is more common, and this will need more funding.

He adds: "It's not a case any more of if there will be more investment - for us to have a sustainable, supportive social care system we need to be dealing with some of the challenges now.

"We hope Wanless will clarify the case in the way he made the case for health care. I believe the evidence for investment in social care is even more overwhelming than it was for health care."

However, last week's revelation that the government might not legislate on the green paper's proposals because of their financial implications suggests that any substantial increases in funding will be difficult to achieve.


Need for direct action
Statistical evidence shows why there could be some mileage in the suggestion by Nick Danagher, executive director of the National Centre for Independent Living, that the government should create a national agency to oversee direct payments.

Fewer than 22,000 people were receiving direct payments in late 2004, seven years after they were introduced, according to the Commission for Social Care Inspection. 

Although this is a 70 per cent increase on the previous year, it does not represent a huge return on a system that has the wholehearted support of most people already receiving payments. 

Nearly three-quarters of people interviewed last year for a commission report backed the idea that older people needing social care should be given money to choose and pay for services.

Direct payments were introduced in April 1997 for adults of working age, and availability was extended in 2000 to older disabled people, carers and parents of disabled children, and 16 and 17 year olds.

But, in September 2004, just 4,365 older people were receiving direct payments. There are also huge variations in take-up across the country, leading to Danagher's call for a national agency to ensure consistency.