There was one telling thing about the Care
Quality Commission's report on Castlebeck's services, published yesterday,
following the uncovering of alleged abuse at Winterbourne
View, one of the company's hospitals last month.
It repeatedly describes the people at Castlebeck's hospitals as
"living" at the hospital. But people don't live in hospitals - they just stay there for a finite amount of time.
I don't point this out to pillory the CQC, it's a sector and society wide
culture issue.
Despite much evidence to the contrary, it's still seen as acceptable for people
with learning disabilities to live in a medicalised setting. Not something we
would expect of anyone else.
It's that culture which ultimately leads to one
in five people in learning disabilities hospitals being there for five years or
longer.
That's why it doesn't surprise me that much when the CQC finds that patients in
Castlebeck hospitals didn't have much in the way of input to get them out of
hospital. Until that changes problems like those at Castlebeck will continue.
July 2011 Archives
However, they are not the only ones.
This morning the BBC carries a story revealing that concerns about Winterbourne View, the hospital where alleged abuse was uncovered, prompting the Care Quality Commission's inspection, were not listened to by the local council.
Nineteen complaints about staff behaviour were logged in the previous five years.
It begs the question, now we know that Winterbourne View was not an isolated case, what's the chances that this happened elsewhere?
It's pretty fundamental stuff with information on identifying risk, the existence of multi-agency safeguarding procedures and when to refer to council adult protection teams. Hopefully it should be of use.
Well a bunch of MPs and peers want to ensure that ministers do not forget him too, amid concerns that the Treasury in particular are not too keen on the £1.7bn annual price tags for Dilnot's blueprint.
The chairs of several all-party parliamentary groups - carers; complex needs and dual diagnosis; dementia; disability; Down's Syndrome; housing and care for older people; learning disability; myalgic encephalomyelitis (ME); multiple sclerosis (MS); Parkinson's; social care - have written to the PM, chancellor and various other cabinet types with a list of demands for reforming care funding.
So here they with some thoughts about their feasibility:-
- Publishing a White Paper on reforming care by 2 April 2012 - this should be achieved.
- Publishing legislation on the same in the 2012 Queen's Speech - this is likely but not certain.
- A financial settlement to ensure local authorities can deliver a fairer care charging system - almost impossible if it means more funding for social care from Whitehall over the next few years.
- Resources to support meetings organised across the country to support public debate on care funding - I imagine the government will do this in some form in the autumn.
- Continue to use the expertise of Andrew Dilnot and the other members of his commission, Jo Williams and Lord Norman Warner, in the run-up to the White Paper - I imagine this will happen.
Are ministers listening?
The take-up of health checks by people with learning
disabilities has slowed over the last year, official statistics show.
What's more, I suspect it may get worse.
The statistics from the Learning
Disability Observatory show that half of people with learning disabilities
are receiving the free health checks, which can make a real difference to
people's lives by picking-up simple problems which often go unnoticed.
However, the take-up rate has increased by only eight percentage points this
year, compared with 16 percentage points the year before.
Almost always when you roll out a programme like this you expect the easiest to
identify to be picked-up first and then things start to get more difficult. But
this can be offset by a greater level of awareness in the community. To see the
growth rate halve when the programme has only reached half the population is disappointing.
What's more the government this year disbanded the Valuing People Now project
team, which was tasked with driving this agenda forward. So there is no one in
central government dedicated to making sure progress continues.
This was one of the more straightforward recommendations from Valuing People
Now so it also doesn't raise too much hope for the rest of the objectives. I
wait to be proved wrong.
The government has, today, released figures for the latest set of new claimants of employment and support allowance.
It continues the trend we have seen since the benefit was introduced in October 2008 with 39% found fit for work, 7% entitled to the highest rate of support and 17% put into the work related activity group.
What's more the numbers back up the select committee's report, which says that the assessments are beginning to get things right first time, more often than they used to.
So, it's fair to conclude that while things are far from perfect they are improving.
Much focus has been given to the assessment itself and how well it serves people. But this has largely ignored the sizable number of people who drop out of the process before it is even complete.
That number has remained fairly static. It accounted for 40% of applicants (18,100) in November 2008, not long after the benefit was introduced and accounted for 35% of applicants (19,600) in November 2010, the latest month for which there are statistics.
The common explanation given is that they were probably just trying it on anyway and knew they weren't eligible. But that's a lot of people trying to play the system, especially when you consider fraud rates for most benefits only run to single figures percentages.
Now improvements for people who stick with the benefits system are starting to take hold, perhaps its time to look at those who don't make it to the end of the assessment.
This is a guest post from our welfare rights columnist, Gary Vaux, on proposed changes to housing benefit for people in supported housing:- This is a very interesting paper and it has clear and substantial implications for social care providers. The current system of funding 'supported accommodation' is a mess and the current housing benefit rules don't fit well with how housing and care are commissioned by local authorities.
Special provision is made within housing benefit where landlords provide the additional support that many tenants require, but in practice there is often a separate contract to provide firstly the accommodation and secondly the support. This disparity causes confusion and inconsistencies, and forces many commissioners, landlords and care providers into complicated and downright devious contracting arrangements, simply to maximise housing benefit revenue.
The previous Supporting People funding stream that local authorities also used to fund care costs was wound-up in April 2011 with the money involved (notionally) being incorporated into the government's overall formula grant for councils.
The Department for Work and Pensions proposal is to simplify this process for 'ordinary' supported housing tenants, possibly by introducing a flat-rate payment into their housing benefit to meet support costs. This may vary geographically but the principle would be to move from a system that is based on detailed consideration of each scheme to one where payments were made straight to the tenant.
This would apply to schemes such as sheltered housing, women's refuges, hostels for ex-offenders and group homes providing lower-levels of care and support. This would fit well with the introduction of universal credit in 2013, when housing benefit is abolished for new claims.
There would then be a separate funding mechanism for the support costs of the much smaller number of individuals in 'specialist' schemes, with the support funding being handled outside of the housing benefit system, possibly by social care providers and possibly even linked to personal budgets. If you think that this looks remarkably like Supporting People Mark II, I wouldnt disagree too strongly.
Reform is vital as the current funding and commissioning system for supported accommodation is not fit for purpose now, and probably never was. Whether the proposed two-tier system, introduced on a 'cost neutral' basis, will do any better is still open to debate.
According to the questionnaire I am a pioneer and am therefore receptive to new ideas and new ways of doing things.
This all may sound like gobbledegook, but it is a recognised social theory called Values Modes that says people are either settlers, prospectors or pioneers.
The consultancy iMPOWER says social workers should be using this in their work to help in the rollout of personalisation, particularly among elderly clients.
The characteristics of the groups are:
Settlers:
- Need to hold on to what you've got.
- It's a "Them vs Us" world.
- Worry about crime is never far away.
- Clear sense of right and wrong. Rule breakers should expect just retribution.
- Strong preference to socialise with "people like me".
- Family/Community/Group is important - nationality, town, football team ..
- Generally rather resistant to change.
- Priority is to get "Me" known out there.
- Clear optimism about life. The world is a big opportuinity.
- "Savvy". Aware of what's going on around.
- Earning and spending money are crucial activities.
- Ambitious - position, power and visible success are important.
- Rules are "flexible" (more like "guidelines").
- Fascination and curiosity with the world.
- Unashamed acceptance of some larger purpose to existence.
- Knows that knowledge usually leads to better questions rather than better answers.
- Sometimes seen as a bit pompous or touchy-feely.
- Needs activity, variety and a degree of ongoing change in life.
It's unlikely the government will listen given they've attached such a priority to localism and therefore scrapped them.
However, it's worth rehearsing the argument in favour of their return. In essence it boils down to money can be directed towards specific areas of social care and that without them social care is suffering.
This is because without the sure-fire directed grant, it was impossible to know whether it is getting all the relevant resources or whether some are being directed towards potholes.
Against this comes the argument that London can't really know what the priorities are in Leeds, for example.
Interestingly Sally Warren, the Department of Health's deputy director for Social Care Strategic Policy & Finance, was sympathetic, but pointed out this was not what the Local Government Group said it wanted. The government had only acted on what LGG had called for.
This is a story that will run and run and run.
Some in local government believe there may be an element of top-slicing or being slow in transferring the funding by PCTs.
Others say that local government has to share some of the blame in not putting forward adequate plans to the PCT, which can't just hand money over without knowing how it will be spent.
Paul Heynes, director of resources at Croydon's adult social care team, says the only way to resolve this is for the Department of Health to commission an outcomes survey to get to the bottom of how much reached the council and how it was spent and what the outcomes were. He thinks this may force some transparency into the issue.
Sally Warren, the Department of Health's deputy director for Social Care Strategic Policy & Finance says if anyone is having trouble in accessing these funds then to tell DH, though she stresses she thinks this is going well.
It includes video, audio and interactive guides on issues including supporting people to make decisions, making more complex decisions and what to do when there is disagreement.
For more information on carrying out a mental capacity assessment, see our interactive guide to assessments.
That is the apparent truth behind proposed changes to housing benefit for people in supported housing mean?
They are designed to revise how additional housing benefit payments are made to supported housing tenants. Such payments are designed to take account of how their additional needs impacts on their housing costs (i.e. the need for people with multiple or complex disabilities to have specially designed or adapted housing, for instance).
However, the government argues, the current system is out of date, because it denies support to some people in need (people in private, as opposed to social housing, or those whose landlords do not provide care or support) and provides almost unlimited help to others.
The key proposals are to split these clients into two groups:-
- People with lower-level needs, who often receive support through hostels or foyers. This group would receive the standard rate of housing benefit for their area plus a top-up to acknowledge the extra costs of their housing.
- People with higher-level needs who would receive a special rate, decided by local authority care and support staff (rather than housing benefit staff, as at present).
Interestingly, sector bodies appear to be taking this message on board. Here is a statement from Mencap, the National Housing Federation (which represents social landlords), the Association for Real Change (which represents learning disability providers), the Association for Supported Living and housing advisory service Housing Options:
"We are reassured that the DWP says this is not a cost cutting exercise and that the consultation does not seem propose major changes for people living in local authority or housing association supported and sheltered housing. We agree that there is a need for reform of the system to ensure that it is more transparent and open. However, we must ensure that the vulnerable, disabled and older people have somewhere to live that suits their needs and enables them to live more independently in their communities in the long term."
Other response are less charitable, however. We've also seen this from housing benefits consultant Chris Smith of Housing Benefit Help:
"These proposals by the Department for Work and Pensions are intended only to cut its own budget and make its own benefit administration simpler. They take no account of the knock on costs of the hardship caused some of the most vulnerable members of society. There are problems with the existing system but these proposals are not the answer."
This should be one to watch.
Andrew Hannam and Lindsey Connett, solicitors at Foot
Anstey, represented families of people with learning disabilities who were victims
of abuse at Budock
hospital in Cornwall five years ago and are now engaged in taking legal action against Castlebeck, the owners of Winterbourne
View. Here they argue this
week's report into alleged abuse at Winterbourne View shows the lessons
of Budock have not been learned.
The CQC report found that there was "a systematic failure to protect people or to investigate allegations of abuse". The report found that there were major failures by Castlebeck in ten essential legally required standards of care.
But this is not the first time such a report has been published. In July 2006, the Commission for Social Care Inspection and the Healthcare Commission (later to become the CQC) published a joint review of services provided to adults with learning disabilities living in the care of the Cornwall NHS Partnership Trust. The investigation centred on allegations of assault and abuse at Budock Hospital in Falmouth.
That report found "institutional abuse was widespread, preventing people from exercising their rights to independence, choice and inclusion".
Considering the two reports concurrently, there are clear similarities, despite the nearly five years between the publications.
Continue reading this analysis after the jump
Image by mendak on Flickr
You can submit examples through Scie's good practice framework page.
Social work blogger Fighting Monsters has posted critically about this today, speaking from her own experience of the opening up of social care to a non-public sector providers from the early 1990s onwards, and the extension of choice to service users.
Here are a couple of choice quotes:
"I do not want any private company to make a profit on my potential need for services for my back pain, my hearing or a child's wheelchair."
And
"I turn back and look at what has happened in social care. Choice has been extended in wonderful ways to those with the loudest voices but in some ways those with the highest needs have been left behind. That is my main concern about the introduction of private into public."
Are you listening Andrew Lansley?
Care funding analyst James Lloyd (head of think-tank the Strategic Society Centre) has written a really informative piece about why the Dilnot report will not open the floodgates to lots of care insurance products.The key point he makes is that Dilnot's proposed £35,000 cap on care costs for individuals is based on "notional care packages" devised by local authorities, setting out what someone would be entitled to were they eligible for means-tested local authority funding.
Such care packages are based on need, not disability - i.e. they take account of the support people receive from family carers and reduce notional funding accordingly.
In his piece for Money Marketing, Lloyd says: "Strictly speaking, this liability is uninsurable. Why? Insurers can only price care insurance policies on the basis of trends in disability and longevity. But in addition to length and level of disability, under the 'capped cost' model, a person's £35,000 liability is determined by the availability of informal care, and how much a council gives individuals with a defined level of need. These are not things that insurers can price for."
Good assumption-busting stuff.
Board members at government disability employment business Remploy are facing a protest this morning from staff over plans that could lead to the scrapping of most or all of its 54 factories, which employ 2,800 disabled people.
Ministers recently accepted recommendations from a review into disability employment support by Radar chief executive Liz Sayce. This would end public funding for Remploy factories, leading to the closure of many, with those able to survive commercially turned into employee-owned companies.
Remploy staff have reacted angrily and are staging a protest this morning at its Leicester offices to coincide with the latest board meeting.
The Unite union says it has 1,000 grievance letters against chief executive Tim Matthews over the manner in which he wrote to employees regarding the recommendations of the Sayce report. The union is calling on him to resign.
Unite wants to meet board members this morning and if it does not get its wish will go straight to disability minister Maria Miller, calling on her to reject the Sayce report and bring in new management at Remploy.
It looks like the company will be in for a tough time.
(Image on Flickr from memspring)
Guest post by Daniel SibthorpeCare services minister Paul Burstow has released a strategy regarding the prevention of suicide and better support for the bereaved.
The good news is that suicide rates are falling - however, one person took their own life every two hours in England in 2009.
The strategy has six main aims:
• To reduce the risk of suicide in high risk groups, such as prisoners.
• To improve approaches to improving mental health in specific groups, such as people with depression, people with alcohol addiction or veterans.
• To reduce access to the means of suicide in order to restrict the number of suicidal deaths.
• To provide better information and support to those who have been affected by suicide.
• To support the media in presenting sensible approaches to suicide and suicidal behaviour.
• To support research, data collection and monitoring.
There is a particular focus on supporting family members of people at risk of suicide to take preventive action. The government has also recently updated the Help is At Hand booklet for people who have lost loved-ones through suicide, and Burstow has written to the Royal College of GPs, The Coroners' Society and the Association of Chief Police Officers, calling for this to be disseminated more widely.
"It's essential that family members get good emotional and practical support if they've lost a loved one to suicide," said Burstow.
An inquiry into providing dignity in care to older people in hospitals and care homes has been launched today by Age UK, the NHS Confederation and the Local Government Group.It comes in the wake of a string of reports that have highlighted the lack of dignity in care for older people - particularly in hospitals - and is designed to identify what older people and their families want from care and how it can be delivered. It is due to report next spring.
(Image from Age UK website)
A picture is worth a thousand words - or may be many more.And the portrait being held up of Islington pensioner Roy Aldridge shows a life that can't be summed up in a thousand words.
The portrait by painter Patrick Michael Lee was inspired by a photo he saw of Roy at 'Street Stories', an oral history project for St Mungo's and a photo of him appeared in an accompanying exhibition shown at the London School of Economics..
Former Whittington Hospital porter Roy, 69, is a resident at the Hilldrop Road housing project in Islington - a supported housing project for older men who've experienced homelessness and managed by the charity St Mungo's.
Proposals out yesterday from the Department of Health mark the latest frontier in a long-running debate on how far people should have the freedom to use personal budgets or direct payments as they like, and how far the state has a duty to protect them from potentially unwise choices?
The exact proposals would mean that, while domiciliary care agencies would have to register with the Care Quality Commission, individuals providing care purchased by families on behalf of service users would not. This would take several thousand individuals out of regulation.
The arguments in favour seem sensible: the current situation creates a lot of red tape for families and the benefit of regulation outweigh the costs.
However, the plan is bound to raise safeguarding concerns, particularly given that we are talking about people (typically family members) organising care on behalf of a service user, rather than the user arranging it themselves.
The consultation is open until 7 October. It should be an interesting one.
The fact that people with learning disabilities spend years on end in
specialist hospitals has become the norm.
The last Count
Me In census of learning disability inpatients, which was published this
April, but conducted last March, showed an even higher percentage (31%) of
people staying five years or more.
Either figure, given this form of care as a long term model has been
discredited since 1993 by the likes of Jim Mansell, is unacceptable.
Community Care didn't report the story in those terms in April (we went with the mental health and race angle), neither did the
Guardian, which is the most sympathetic mainstream media outlet (it
also ran with the race angle), it wasn't even news. It was a long term trend
once more confirmed way-down in a big statistical report.
Yet, when we collected these latest figures and put them to a variety of
experts and politicians they were consistently appalled. One commentator
laughed, not because it was funny, but because it was so exasperatingly familiar.
That is the real scandal. And one which must stop. Hopefully, in the light of the
Winterbourne View case, these numbers will begin to prompt greater commitment
and action from those able to change it.
Guest post by Daniel SibthorpeParkinson's UK has today issued a warning to NHS commissioners not to cut specialist Parkinson's nurses, but to do the opposite and invest in them more.
In a campaign launched today, the charity says that primary care trusts who cut posts to save money will end up spending more on healthcare.
Nurses help co-ordinate care for patients, manage medication and provide information, advice and emotional support. A survey of patients by the charity found that two-thirds rated their nurse as the most helpful practitioner in helping them understand Parkinson's.
While cuts do not appear to be happening yet, the charity has found that almost a third (29%) of specialist nurses feel insecure in their posts, with NHS resources under increasing strain.
Parkinson's UK estimates that cutting the 60% of specialist nurses who are community-based would cost the NHS £19.5m a year in increased hospital admissions and demands on consultants' time.
The charity estimates that a single nurse could save an average of £80,000 a year in unplanned admissions and £44,000 in consultants' time. So it is calling for another 60 nurses to be employed, to ensure everyone has adequate access to them, which it says could save the NHS £7.1m a year.
Assuming Parkinson's UK's figures are correct, this should be a case that persuades NHS commissioners. But will it?
Is the Care Quality Commission
too health-centric? The
National Care Association thinks so.
The NCA has written to care services minister Paul Burstow to demand more
social care expertise at the top of the organisation and that it be split in
two entirely.
A lack of social care knowledge has been the bug-bear of many cross-sector
organisations because social care is all too often seen as the little brother
to health services in the eyes of policy drafters.
There has been a dearth of good news to write about the Commission over the
last year, so I can understand why the NCA is fed-up. So, it's not really a
surprise that this would happen now. But just because making a connected
regulator work is difficult, doesn't mean we shouldn't continue to try.
It's also possible there may be a redressing of the balance if the government
pushes ahead with plans for reform of social care, which would probably up its
profile in public and policy discussions.
But dissatisfaction with the board members is not confined to NCA. Other
provider representatives have frequently raged to me about the seeming inaction
of other board members in the face of the shortcomings of the CQC.
Whether having social care experts in charge would make any difference,
however, seems far from certain.
Let us know what you think in the comments.
Full list of demands after the jump.
Community care law researcher Lucy Series (who blogs and tweets as The Small Places) wrote a post last week showing that inspections of care homes in 2010-11 were 6% of the level they were in 2004-5).
In a fascinating piece, she charts the reasons behind this: yes, cuts, but also a change in approach to regulation: one that took the view that inspections on previous levels were unnecessary, and a better use of scarce resources would be to gather intelligence on all services and target inspections at those that showed the greatest level of risk.
Series has gathered some great facts and figures through the Freedom of Information Act. One I particularly like shows that the proportion of social care regulation expenditure spent on inspections fell from over 50% under the Commission for Social Care Inspection to under 40% the Care Quality Commission.
She's conducting some research into this area which will challenge the basis for the "risk-based" approach to regulation.
The big story of the weekend seemed to be all the
resignations of journalists and police over the New of the World scandal, which
is why this particular resignation may have sneaked under your radar.
Paul Brosnan, chair of Castlebeck,
resigned over the weekend following the expose of alleged abuse at Winterbourne
View hospital by BBC Panorama.
The company's statement said: "Paul Brosnan has told the board that he
believes the company needs a chairman with relevant health and social care
experience at this time."
The Observe reports, that Brosnan is a former banker. It's difficult to imagine
how that would qualify you to run a care business.
Also, why was it not necessary to have someone with a bit of knowledge of
social care or learning disability in the top job when the Company was not
making headlines for all the wrong reasons?
This news broke just a day before the CQC published its report on Winterbourne
View, which shows that the hospital had inadequate vetting of the qualifications
of staff. Well, it would seem that trend runs all the way up to the top
leadership.
Kensington and Chelsea
council is set to face pickets from disabled after a campaign was launched to
get cuts to one woman's care overturned.
Earlier this month Elaine McDonald lost
a landmark Supreme Court case to keep her night time care, which helped her
go to the toilet. Instead the council will now only provide her with incontinence
pads.
Now, national disability organisation RADAR is trying
to rally enough support to picket the councils cabinet meeting next Thursday.
On the event's
Facebook page it wrote: "Personal assistance is vital to many disabled
people's independence and safety. Disabled people with complex health and
social care needs who cannot move unaided should never be left alone at night in
case of a fire or a sudden deterioration in their condition."
I can't say I'm too optimistic about the chance of success. The council spent a
lot of money on lawyers defending its right to make this cut. It knew it
wouldn't be popular, so I'm not too hopeful that this will be embarrassing
enough for them to backtrack.
That said, the fact a national charity is getting involved at this local a
level says quite a bit about how important this case is. And you have to
respect the fact that they are having a go.
Things just keep getting worse for learning disability
hospital provider Castlebeck.
The BBC reports that staff
have been suspended at one of its hospitals in Leicestershire.
That's the third hospital which has had staff suspended in as many months.
Castlebeck is the owner of the
Winterbourne View hospital which was the subject of an undercover
investigation by BBC Panorama, which uncovered alleged abuse.
True story.At a reception last night hosted by the International Longevity Centre I managed to collar Martin Green, chief executive of the English Community Care Association. He seemed to be in a bit of a hurry to get somewhere, but I'd wanted to ask him a question earlier in the week but had been unable to get hold of him.
"What do you make of this week's news that care home fees are dropping by 2.5%? Is there anything which can be done," I asked.
"I'm off to see the Wizard of Oz," said Green, as he rushed for the door with some friends.
Yes, it seems, the funding situation is that bad.
Image by Everett Collection/Rex Features
This is one of the conclusions in a monitoring report on NHS performance by the health think-tank the King's Fund, which found that around half of England's hospitals may fail to make the big efficiency savings expected by ministers.
The report - a survey of finance directors at 29 NHS trusts - showed that, while organisations are meant to be making 4% productivity gains, 13 of the 29 have to save 6% or more of their budget.
In eight of those the finance directors said they were uncertain that they could do so, while three said they expected their trust to end the financial year in deficit.
On delayed discharges the report finds a slight rise from December - though it describes this as remaining stable (just) and nowhere near the big problems of 2003/2004.
But it noted that an earlier report of its had warned that unless all councils can achieve unprecedented efficiency savings, the tough spending settlement for local government could open up a funding gap of £1.2 billion or more in social care by 2014.
That report concluded that such a gap would have knock-on effects for people needing NHS care as there will be more emergency admissions to hospital, delayed discharges and longer waits for treatment.
The report also says finance directors viewed lack of integration with social care as a barrier to improving on financial performance. As we all know this is a constant problem despite the consistent attention paid to improvements.
Integrated working shouldn't be as difficult as many seem to be finding, but as our video from earlier this year on joint working in Portsmouth showed, good practice in this area is as much due to personalities and leadership as it is to anything else.
Guest post by Daniel Sidthorpe
Towards the end of her husband Malcolm's life, carer and dementia campaigner Barbara Pointon found herself second guessing what his last wishes were.
Dementia had robbed him of the ability to talk or make facial expressions. They had no plan in place for the palliative care he should receive and he could no longer make one.
That's why she spoke movingly about her experience at the launch of the dying matters coalition's guidance for professionals on palliative care planning for dementia entitled Difficult Conversations, last Tuesday.
The main objective of the booklet is to provide social care practitioners with information on how to deal with dementia and ensuring you have prepared yourself for when a person approaches the end of life.
The guide stresses the importance of having the conversation about the end of life early so families and services can prepare and provide for the wishes of the person at the end of life. It is important for these conversations to happen because it could stop your carer constantly second guessing what you would like to do.
Through this booklet, the conversation between people about dementia can be made a lot easier and more reassuring.
The Palliative Care Funding Review did not go far enough in supplying more cash for hospices, the chair of the All Party Parliamentary Group on Hospice and Palliative Care claimed this week.
Fabian Hamilton said he did not agree with the review anyway because hospices funding never reached the targets that it was promised by the NHS. He pointed to the previous govenrment's desire to have 50% of hospice funding from the public purse, stating this only ever reached 25% is his own constituency.
According to Hamilton, the review said: "You're doing OK without us so you don't actually need the extra money".
He added: "Hospices have got to work harder to raise the money to keep themselves going, and ultimately if they don't raise the money, then the brilliant and wonderful care they give people at the end of their lives, as well as the palliative care, is just not going to be there for everybody."
When asked about the impact of lack of funding, Hamilton said he was frustrated that the government do not put money into things that cost money now but will save money in the future.
In case you were in any doubt as to how bad the financial
climate is for care home owners at the moment analysts Laing
and Buisson have quantified it.
Homes are receiving an average 2.5% real terms cut in their fees.
What can they do to change this? Well, very little in the courts it would seem.
Yesterday, the Birmingham Care Consortium, which has over 80 member
organisations, had its case for a judicial review to overturn a council freeze
on fees rejected
by the High Court yesterday.
The Birmingham Mail reports that the judge said the appeal was premature while
the council were still finalising fee levels for the coming year.
That doesn't seem to leave much room for manoeuvre for beleaguered care home operators
and the suggestion of Laing and Buisson's chief executive, William Laing, that the government should step in to
set fee levels will probably start to look increasingly attractive .
Alleged
abuse has been uncovered at another Castlebeck care home (the provider also
owns Winterbourne View, where alleged abuse was exposed by Panorama last
month), resulting in four members of staff being suspended.
In the BBC's video package this morning the reporter, whose name I didn't
catch, ended the report saying this second case raised questions about how
frequently these homes were inspected.
Well it does, but regular readers of Community Care will already know the
answer to that question - not enough.
For four months over the winter CQC
ceased inspecting hospitals for learning disabilities (which form a large part
of Castlebeck's provision, although not Rose Villa) at all. Rose Villa,
however, is a care home not a hospital, but the inspection rates for these have
not been a lot better - falling
70% in the first six months of the current regime, which came in in October
last year.
I have not yet heard any figures to suggest this has substantially improved,
though I understand inspection rates are rising incrementally.
That's not to say CQC are the only people with responsibility here. The commissioner,
be it the PCT or the local authority also has a responsibility to check what
it's paying for and the senior management of Castlebeck should keep tabs on it
as well.
The one good piece of news here is that it appears this started with someone
inside the organisation blowing the whistle and Castlebeck have subsequently
taken action internally with the first of these suspensions. That's an improvement
on what happened at Winterbourne View at least.
Labour maintains it is increasingly unclear what the government proposes to do in relation to failed businesses the size of Southern Cross nor is it clear what other regulatory powers it intends to introduce.
The latest position appears to be one of further consultation of its plan in the Health and Social Care Bill to give Monitor a role in adult social care to address both anti-competitive failure and provider failure.
Labour's point is 'We'd love to know more about your plans' and here is where things are unclear.
Shadow care service minister Emily Thornberry tried again during an urgent question on Southern Cross laid down today.
Thornberry wanted to know how any plans put forward by landlords would be stress-tested for financial viability and how this will guarantee that all homes are run to a sufficiently high standard. Furthermore who will carry this out? If it is adult directors they will need help, she said.
Care services minister Paul Burstow admitted today: "We need to ask questions about the regulatory framework that existed when this business model was established and we need to make sure that we've the tools in place when a large provider has problems."
However in reply to a question from Lib Dem MP Andrew George about the need for further measures to protect people because of the government's plans to expose more people in health and social care to "capital", Burstow said he wasn't keen to jump to conclusions and instead wanted to see "robust regulations on the ground."
However now wasn't really the time while landlords, lenders and other interested parties were working towards a "consensual solution" to fully outline plans.
The British Association of
Social Workers may fight cuts to council services together with disabled
people's campaign group Broken
of Britain.
Earlier
this week Broken of Britain wrote to BASW calling on it to instruct its
members not of take unethical action to reduce people's care. It was concerned
that a Supreme
Court ruling last week, which upheld councils' rights to cut care without
an explicit reassessment of need.
Replying to Broken of Britain's concerns Hilton Dawson, president of BASW,
said: "BASW fully supports your concerns about the issues raised by the
Elaine McDonald case and would be happy to work jointly with Broken of Britain
on a whole range of campaigns."
Image by Clevercupcakes on Flickr
However, the calculation of this figure seems rather flawed to me.
The APPG explained the calculation like this:
The total occupancy of hospital beds is approximately 105,000 (NHS statistics 2009/10). Up to one quarter, or 26,000 of hospital beds are occupied by someone with dementia. It costs approximately £1,500 to care for someone with dementia in hospital for a week (NHS tariffs 2010). If we cut the number of beds by 12 per cent this would therefore free up over £1 billion a year.
But that assumes that 10% of the total beds that are
occupied need not be. There is probably some truth in this as we know from
previous research that dementia patients spend longer in hospital. However,
there may be perfectly legitimate reasons why most are in hospital, which may
not be related to their dementia. After all, dementia patients are often old
and frail by the demographic nature of the disease.
Cutting nearly half of the beds of dementia patients seems a rather ambitious
target to make the savings to pay for dementia care in the community. It is not
really clear from this calculation, or the full report, whether it will work
It has found significant failings to meet obligations to promote disability, race and gender equality in a sample of primary care trusts and strategic health authorities.
Those of you with long memories will remember that this is a longstanding issue - the EHRC's predecessor, the Disability Rights Commission, wrote a damning report on the NHS's failure to meet disability equality obligations in 2006.
Longstanding problems include failures to take sufficient account of people's learning disabilities by making reasonable adjustments.
The latest report identifies issues including:
- A tick box approach to meeting equality duties.
- A lack of data on performance.
- Failures to take sufficient account of equality duties in leadership, commissioning and employment issues.
Last month, Liz Sayce, chief executive of RADAR, published a report she wrote for the government setting out her vision for employment support in the future. It is the conclusions and recommendation of this report which form the basis fo the government's consultation.
You can send resposnes to the consultation to the Department for Work and Pensions.
Social workers have been told they should fight stealth cuts
to people's care entitlements sanctioned by a court ruling last week.
Last week the Supreme
Court upheld councils' right to make cuts to people's care packages without
an explicit reassessment.
Today, disabled campaigners have sent a letter to Hilton Dawson, chief
executive of the British Association of Social Workers (BASW), urging him to
tell his members to refuse to implement cuts stemming from the ruling.
"Acting in the way that has been sanctioned as legal for local authorities
by the Supreme Court runs counter to ethical practice as set out in the Codes
of Practice for registered Social Workers in the countries of the United
Kingdom and the BASW/IFSW Codes of Ethics," wrote Rhydian Fôn James,
campaigner with Broken of Britain.
Furthermore, James said at its least the judgement could damage the
relationships between social workers and disabled people.
"As an organisation representing social workers, I am sure that BASW will be
concerned that the judgment and the cuts may further erode the trust of
disabled people in their social workers, and further damage the social work
profession. Social work as a profession has experienced a great deal of unfair
criticism in recent times, with social workers struggling to cope with reduced
resources, unreasonable and conflicting demands, and a hostile press. The
precedent set by the McDonald judgment could worsen the hostility towards the
profession," he said.
It's an assessment which was reflected by Douglas Joy, senior solicitor at the
Disability Law Service, which brought the case, when I spoke to him last week.
"It makes the assessment procedure less formal," he said. "It raises the
possibility that a social worker may just have a chat about the care package and
suddenly the service user finds their care package has been reduced."
I have asked BASW for a response to see if they will be taking up the stance,
which Broken of Britain have advocated and will post something when I get it.
Full letter to Hilton Dawson after the jump.
Do you agree that social workers should refuse to implement cuts which follow
from the judgement on ethical ground? Let us know in the comments.
Image by JD Hancock on Flickr
This week seems to have the letter writers out in force.
Yesterday, care services minister Paul
Burstow was told to intervene to stop cuts to services.
Today, the Association for Supported Living is trying
to rally support from MPs to pressure the government to set a timetable for the
abolition of institutional living for people with learning disabilities. The
push comes in the wake of the abuse scandal at Winterbourne
View hospital uncovered by BBC Panorama last month.
It writes: "We call on the Government, as a matter of urgency, to compel
commissioners to set a timetable for the provision of alternative,
community-based services for all of these people."
Full letter after the jump
The move was prompted by this week's Supreme Court ruling, which upheld councils' right to remove care without an explicit reassessment of need, and the pronouncement from the Association of Directors of Adult Social Services (ADASS) today the dire state of care was likely to get worse before it got better.
WRVS argues only the government can intervene to get council to spend money on preventative activities. "WRVS believes this is where central government, as the overall custodian of public spending, must intervene and insist that investments that deliver a return for the taxpayer are made," it said.
The letter adds: "WRVS proposes that the Department of Health requires all local commissioners to introduce mandatory clinical audits of emergency readmissions to hospital amongst the over 65 age group. These audits could identify whether readmissions were taking place as a consequence of service failure or restrictions in the availability of social care services."
Full letter after the jump
It's interesting to note the comments
of Lady Hale in her judgement in the McDonald v. Kensington and Chelsea case, delivered
yesterday.
As the only dissenting judge (and the most experienced in social care law) she
gave campaigners hope that further avenues for challenging reassessments of
need may still be open.
Elaine McDonald lost her case, which was an attempt to get the council to reinstate the provision of
care staff at night to take her to the toilet because of mobility issues and
instead will have to wear incontinence pads, as recommended by the council. But
Hale dissented from the majority verdict.
She was concerned the case had not been fought on different grounds. She summarised
the case saying: "Is it lawful for a local authority to provide
incontinence pads (or absorbent sheets) for a person who is not in fact
incontinent but requires help to get to the lavatory or commode? It raises an
important point of law on the proper interpretation and application of section
2(1) of the Chronically Sick and Disabled Persons Act 1970. Unfortunately the
parties have not addressed themselves to this point."
She said that had they done so they would have been on firmer ground.
Hale pointed out that in order to meet this section of the act an authority
must ask itself first what the person's needs are and then what is necessary
to meet them.
However, she argues the question of when local authorities can rightly consider resources, as opposed
to need, in this process has been confused by case law and guidance. And that the
balancing of practicality has overshadowed hard legal principle.
For anyone wishing to take up a similar case this may prove a much more lucrative argument to put.
Image by University of Salford on Flickr
The audit said it had paid nearly 17.5% over what it really should. Some clients never even got meals the council was applying for, the Calderdale Courier reports.
The report said there was little contract monitoring and the whole system was open to abuse.
In this guest blog post, Stephen Lowe, social care policy adviser at Age UK, says today's Supreme Court judgement in the Elaine McDonald raises the spectre of care services being stripped back to the bare minimum.Going to the toilet may be a basic bodily function but how we do it is fundamental to our social identity and sense of dignity. Our society, and most others, have a whole range of social (and sometimes religious) customs and rules about how we do it. The same could be said about eating, which for most people is about much more than just feeding. Again the act of eating is often essential to our identity. The extent to which social services should be able to save money by ignoring these social norms and just meeting physical requirements is, and probably always has been, one of the most controversial issues in social care.
The conclusions reached by the Supreme Court, published today following the McDonald case (R. on the application of McDonald v. RB Kensington and Chelsea), are essentially about this issue. Ms McDonald was originally assessed as needing help going to the toilet at night as she has a neurogenic bladder. The assessment leading to this decision included consideration of the impact on dignity and psychological well-being if she did not receive help.
At some point this became translated into a simple need to remain safe. Considerations of self-respect, dignity and conformity with social norms - the basic building blocks of personal identity - could therefore be swept away. A simple need to be kept safe could be met by incontinence pads, even though Ms McDonald is not incontinent.
This verdict has huge implications for everyone who relies on local authority support to remain independent, particularly at the current time where local authorities are making unprecedented cuts. If local authorities can reduce care and support to a level needed to just keep people safe, this raises the spectre of care services becoming increasingly limited to the bare minimum needed to warehouse people in their own homes.
This should surely be unacceptable in a civilised society. What we need is a clear statement, in legislation, that draws a clear line in the sand which defines the basic quality of life that society believes people should be able to achieve.
The Law Commission made this point in its review of community care law. The commission does not see its role as being to say how eligibility should be defined, but does say that 'in our view it is essential that the law is clear about basic minimum entitlements' (page 62 of its final report). Moving forward to the next social care bill,, which will hopefully be based on the Law Commission's proposals (and any Dilnot commission proposals that require legislation), this is surely one of the major issues.
There are all sorts of toys on it - the data hungry among you will enjoy the many interactive graphics it provides.
This one shows 50 patients' interactions with health and social care over three years, which can be used to determine their risk of unplanned hospital admissions.
It certainly makes this stuff a lot more accessible, I think.
In this guest blog post, Tes Smith, social care lead at the National End of Life Care Programme, discusses the vital role of social care professionals in developing end-of-life care locality registers.Social care professionals can be forgiven for thinking that a new register held by GPs is unlikely to affect their practice much. But the large number who have some involvement in end-of-life care - and care homes - should actually take a keen interest in the development of end-of-life care locality registers.
An evaluation of eight pilot registers was broadly positive - but noted the need to get social care in on the act early. The evaluation insisted that social care should be represented in stakeholder groups from the start. It noted that social care professionals and care home staff are likely to have a big role in both identifying people suitable for the registers and raising the issue with the individual.
They would also be among the wide range of professionals and services, including district nurses, ambulance services and GP out-of-hours teams, who could access the extensive information on a particular individual.
That reflects the social care ethos of team working to support the individual and the family.
So, you may be asking yourself, what is actually on the registers and how will individuals join the register?
They record key information about a person nearing the end of life, including their preferences around the care they receive and place of death. The latter part of that sentence is important and reflects core social care values. Surveys consistently show that a sizeable majority of us wish to die at home yet around 57% of deaths take place in hospital.
Yes, the registers do record the individual's condition and treatment. However they also clearly set out the person's wishes around their future treatment and where they would prefer to die. This should make it more likely that any decisions made, particularly as a person's condition deteriorates, reflect choices made by the individual - including whether they would prefer to die at home (possibly including a care home).
Registers could also cut down on paperwork, form-filling and the sometimes exhausting questioning of individuals. Information needed by social care professionals working with an individual will in many cases be available through the register.
The evaluation repeatedly notes the need for social care to be involved in early local development of the registers - not least to address the challenge of ensuring the sector can access the IT platform chosen to host it. This will potentially apply to care homes as well as those involved in assessing needs or co-ordinating care.
The evaluation, conducted by Ipsos MORI, also says that while GPs will 'sanction' the addition of an individual to the register and the information that is added on that individual, people working in social care are well placed to identify those who might benefit from inclusion. After all, social care professionals conduct regular assessments while care home staff see their residents every day.
Beyond this, the evaluation suggests that those in social care might be best placed to initiate discussions with the individual. This reflects the need for informed consent. Gaining consent for inclusion on the register is a sensitive issue requiring excellent communication skills and a confidence to initiate a discussion around end of life choices.
Again, social care staff will often have the values, skills and experience to conduct such conversations, ensuring that if consent is given it is informed consent. This includes the individual understanding that the information on the register will be available to a range of professionals. How this information is shared and with whom, alongside protecting confidentiality, are obviously important elements in developing a register locally.
While the evaluation does not flinch from recognising these and other challenges in establishing such registers, the pilots provide possible solutions as other parts of the country begin work on their own registers.
Social care should embrace that work and seek to be in at the start. Based on assessment and advance care planning, co-ordinated care will mean professionals working together to deliver care to individuals nearing the end of life that reflects their choices.
Today's news that Elaine
McDonald has lost her case to get her cuts in care on cost grounds reversed
is just the tip of the ice berg.
That's not just my opinion; it's the opinion of Peter Hay, president of the Association
of Directors of Adult Social Services.
When i asked him earlier today if there would be more councils looking to make
these kinds of reductions, or changes in delivery depending on whose
terminology you're using, he said: "Of course. What do you expect?"
Squeezed resources will inevitable lead to more cuts like this it seems.
"We've got to run lean system which are about doing things cheaply and
efficiently and that's the reality," said Hay.
Hay acknowledged it wasn't desirable but he was of the opinion it was the only
thing that could happen in the current system, with less cash.
The commission has confirmed that, under its proposals, we would continue to have a national system of means-testing for residential care and local systems of means-testing for non-residential services (albeit ones that comply with the government's fairer charging guidance).
This is relatively obvious when you read the report but I just wanted to check given that eradicating the postcode lottery was a key priority for the commission.
What if any reform does the commission propose to the charging system for non-residential services?
The cap would apply to spend on non-residential services as well as residential services. Our report also suggests that government considers the case for including housing assets in the means test for non-residential care, once a cap is in place.
What account if any would be made in the proposed cap on care for the different costs of care in different areas? With one national figure is there a danger that people in more expensive areas will receive state-funded care before people in less expensive areas?
There are many ways in which regional differences play out . It may be possible to devise a complex system which addresses these but we believe that there is value in simplicity and national offer. Further more, the social care system is only a tiny part of total government spending and it is not realistic to expect it to tackle regional disparities.
We know that there is large variation in house prices across different parts of England. Our recommendation to increase the upper assets threshold from £23,250 to £100,000 is specifically designed to help those with lower levels of assets going into residential care - and will mean that they won't have to pay the full £35,000 themselves. For example it will ensure that:
People living in Burnley where the median house price is around £70,000 will pay a maximum of £18,000 on care costs out of their assets.
People living in Bristol where median house price is £170,000 will pay their full care costs up to a maximum of £35,000.
Regional differences work in different directions. House prices vary but so too do care prices (e.g. the average cost per hour of home care is £22 in Windsor, £12 in Wakefield). Rates of universal benefits are national and may go further in some areas of the country.
Will people have been judged to have met the cap based on what they have actually spent on care or what their local authority expects them to have spent in line with their notional package of care? People who fund their care themselves tend to spend more on care than local authorities so may well have spent up to the cap figure before they are deemed to have done so by their council?
People's spend towards the cap will accumulate at the rate of the local authority notional package of care. Local authorities have a duty to find care for people even if they do not qualify for means-tested support. So everyone should be able to find care at the price of the notional package of care. Spending in excess of this would not count towards the cap.
Will people who have needs below the national eligibility threshold but who spend money privately on care be able to count this spending towards their cap figure?
People would not be able to count spending on needs below the eligibility threshold on care. This is really an issue about where the threshold is set. However, we believe that placing a cap on people's lifetime spend will free them up to start spending money earlier.
How far does the cap apply to people who receive means-tested support from the state but are charged for that support (either through the system of contributions to non-residential care services or through "tariff income" charges in residential care) - will they be deemed to have met the cap when their total level of charges for care over a lifetime reaches £35,000?
People's spend towards the cap will accumulate at the rate of the local authority notional package of care - regardless of whether they are receiving mean-tested support. So someone who has a care package of £200 per week and pays £50 per week in charges will accumulate towards the cap at £200 per week.
How will the system of means-testing in residential care apply to people who have met the cap but have assets of between £14,250 and £100,000? Would they be eligible for means-tested support with their general living costs?
If people with assets of between £14,250 and £100,000 have insufficient income to pay for their contribution to general living costs they would receive means-tested support based on our proposed asset thresholds.
The report says that people who have met the cap and are in residential care should no longer receive attendance allowance? Would they have any other benefits withdrawn?
Under the current system people receiving state support towards their residential care lose their entitlement to AA after a certain period of time. We are proposing no change to the current rules; the consequence is that those who are receiving free care because they have reached the cap would lose their AA. We are not proposing changes to eligibility to other benefits.
Here's a bit of a summary of reaction to Andrew Dilnot's report on care funding reform, published on 4 July (this blog post was updated on 6 July at 2.30pm). The cheerleaders
This category appears to encompass the major older people's and disability charities, national care provider bodies like the English Community Care Association, insurance provider Partnership and also council bodies including the Association of Directors of Adult Social Services.
They believe that the proposals are sensible and achievable and answer many of their longstanding concerns about the care system including underfunding, people facing catastrophic costs, the postcode lottery and inadequate information and advice.
The worriers
A vocal sub-section of the cheerleaders, this lot are concerned that the government may not act on Dilnot's recommendations (and who can blame them given health secretary Andrew Lansley's cautious response?).
A representative example is Age UK's comment that it would be "indefensible" for the government to delay its White Paper follow-up to Dilnot beyond next Easter.
The sceptics
The best example of this is social care market analysts Laing and Buisson. It points out that, currently, self-funders often cross-subsidise the relatively low fee rates paid to providers by local authorities, protecting providers' bottom lines somewhat. As the Dilnot reforms would reduce the number of self-funders (by capping private care costs), this could thereby reduce the overall level of fees paid to providers and put them in trouble.
Another example comes courtesy of Institute for Public Policy Research director Nick Pearce in this thoughtful piece in which he questions whether people, left to their own devices, will self-insure themselves against the costs they would be responsible for (i.e. up to the £35,000 cap). "There is a great risk here that myopia about care needs, a continued belief that the state will pick up the tab, or just plain bad luck will leave people without coverage below the new cap, he says. "Dilnot is staking a lot on a system that has no compulsory element to it."
And here's another, from Antonia Bunnin, health and social care specialist at the Office for Public Management. She flags a warning about the suggested limit on residential care living costs per individual of £7,000 to £10,000 and how this could lead homes to squeeze spending on things like food, activities and the physical environment. She warns: "[Dilnot's] may turn out to be too rigid an approach, and may have the unintended consequence of restricting care homes' ability to provide their residents with a positive and personalised experience and a good quality of life."
The opponents: Dilnot is wrong on his own terms
The Dilnot report's central claim is that its proposals would protect people against the potentially catastrophic costs. However, there are some who disagree, including organisations in the care advice sector who are at the sharp end of families in these situations, such as the Relatives and Residents Association and FirstStop Care Advice.
One of their central beefs is with the fact that the cap on costs does not apply to general living costs in residential care (for which service users will face a £7,000 to £10,000 annual charge unless they are eligible for means-tested support).
FirstStop points out that people who are in residential care for five years would face an £85,000 bill - £35,000 for care and £10,000 a year for living costs, which for many would involve selling their home.
While FirstStop is complimentary about other aspects of the report, particularly its emphasis on improving information and advice, the Relatives and Residents Association is pretty brutal.
"The Dilnot proposed cap on contributions will only cover the 'care' element of the resident's needs, it will NOT cover any 'board & lodging' and Dilnot estimates that these costs alone will come to £7-10K per annum," says chair Judy Downey. "The state pension will barely cover this amount. This is hardly the Fairer Care Funding [a reference to the Dilnot report's title] that we were promised."
A similar flavour can be found in this blog post for us from Peter Beresford, chair of user-led organisation Shaping Our Lives and professor of social policy at Brunel University.
Both Beresford and Downey feel that care should be funded out of general taxation and free at the point of access, an option ruled out by the Dilnot commission at an early stage.
The opponents: Dilnot's proposals are regressive
This charge has been levelled at successive attempts to reform the care system, including the Royal Commission on Long-term Care for the Elderly and the Wanless report. All such attempts have involved extending the reach of public funding for social care beyond the poorest to all. As Pearce's blog shows, the biggest gains in cash terms accrue to the top 20% of the population under Dilnot. And, of course, a £35,000 cap is smaller fry for a multi-millionaire, as a proportion of income/wealth, than it is for someone with more modest savings.
The most clear example of opposition on this score comes from the social enterprise United for All Ages, headed by Stephen Burke, a longstanding campaigner on care funding.
It says: "Under the commission's regressive proposals, the winners would be richer families whose inheritance will be relatively protected while most families will face a more confusing and potentially costly care system."
It also believes people won't be protected from very high costs by the proposals.
Burke has always backed a compulsory levy on estates to pay for care (something Spiers from FirstStop has also been an advocate of). However, like free personal care, this option was ruled out by the commission.
Community Care's view
Just to show we don't just sit on the sidelines here's our editor Bronagh Miskelly's comment on Dilnot.
The Dilnot model could be delivered for an additional £0.8bn a year if the cap on individual care costs is put at £50,000 as opposed to £35,000 (Dilnot's preference) and the cap on annual general living costs in residential care is applied at £10,000 rather than £7,000.
Dilnot also thinks his estimates are likely to be on the high side because:-
- Some wealthier people may not seek state help when they reach their care costs cap.
- The costs for people aged under 65 could be less than estimated because of the number of people who acquire a disability in their 50s (and who would thus not be entitled to free care under Dilnot).
- The cap significantly reduces incentives for wealthier people to hide their assets to avoid paying for care.
(Image on Flickr from NHS Confederation)
I've just read through the Dilnot report and while it can't be faulted for its clarity, I'm left with a few questions. This of course just could be me being a little on the thick side and if you have any answers to these please let me know. Here they are anyway:- - What if any reform does the commission propose to the charging system for non-residential services?
- What account if any would be made in the proposed cap on care for the different costs of care in different areas? With one national figure is there a danger that people in more expensive areas will receive state-funded care before people in less expensive areas?
- Will people have been judged to have met the cap based on what they have actually spent on care or what their local authority expects them to have spent in line with their notional package of care? People who fund their care themselves tend to spend more on care than local authorities so may well have spent up to the cap figure before they are deemed to have done so by their council?
- Will people who have needs below the national eligibility threshold but who spend money privately on care be able to count this spending towards their cap figure?
- How far does the cap apply to people who receive means-tested support from the state but are charged for that support (either through the system of contributions to non-residential care services or through "tariff income" charges in residential care) - will they be deemed to have met the cap when their total level of charges for care over a lifetime reaches £35,000?
- How will the system of means-testing in residential care apply to people who have met the cap but have assets of between £14,250 and £100,000? Would they be eligible for means-tested support with their general living costs?
- The report says that people who have met the cap and are in residential care should no longer receive attendance allowance? Would they have any other benefits withdrawn?
(Image on Flickr from purpleslog)
Findings include:-
- A third of women have taken antidepressants at some point in their lives.
- Nearly half of women on antidepressants now have been on them for five years or more.
- One in four women on antidepressants have waited a year or more for a review of their medication.
- Over half of those on antidepressants were not offered an alternative at the time of prescription.
(Image from Platform 51 website)
In a guest blog post, James Lloyd, director of think-tank the Strategic Society Centre, discusses the implications of this proposal and examines how it might work in practice.
The limited liability model is not a new invention. It's an idea that's circulated in the social care funding debate for at least the last decade. For a number of years, it was the official favoured policy of the Conservative Party.
The core principle is that the state should cap the potential costs of care that individuals have to pay for by stepping in and funding care costs beyond a defined threshold.
Why? In part, the rationale is based on what the state can do and what the insurance industry can't. Insurance companies find it extremely difficult to provide long-term care insurance in the same way they sell home insurance or travel insurance. This is because it is so difficult to estimate the chances that someone will need care far into the future, and how long they will need it for. This difficulty in 'risk-pricing' creates a gap in the protection on offer from the insurance industry against the risk of racking-up catastrophic care costs. So - the logic goes - the state must step in and cap these costs instead.
Many advocates have also argued that adopting the limited liability model would be the key to unlocking a private insurance market because individuals would be able to buy insurance against the rest of their liability. However, from a consumer perspective, the limited liability model will make insurance somewhat cheaper, but nothing else. And there are other factors that tend to deter people from buying long-term care insurance, so any effect on take-up may be, well, limited.
However, many different variants of the limited liability model are possible, and policymakers are going to have a lot of choices to think about following the publication of the commission's recommendations.
First, what types of care-related costs should the state be capping? Personal care in the home? Personal care in a residential setting? A key judgement-call of the commission is going to be whether 'hotel costs' should be included in the cap on costs the state provides. As many readers will remember, the last government chose to exclude hotel costs from its vision for a free National Care Service. There are arguments for and against, but the effect on the potential costs that people confront will be massive.
Second, where should the thresholds be set? This will be a big one. To give people certainty, the limits on individual liability need to stay broadly the same over time, after taking account of inflation. They can't jump around every time there's a comprehensive spending review, so policymakers will need to agree a clear framework for setting the thresholds at which individuals will become entitled to state funding, and then stick to it for years to come.
The core argument of the limited liability model - that only the state is really equipped to protect the population against catastrophic care costs - is pretty hard to dispute. Turning this principle into a functioning social care funding system is going to involve a lot of work and a lot of complex choices.
It's not very often you can claim victory over the
government, but today is one of those days.
Yesterday, the government shelved any plans to abolish any of the social care duties
on councils. The consultation which could have seen their abolition caused widespread outrage when it was unveiled in
March.
Indeed the government is now saying that it never intended to get rid of any of these
duties which were on the list as a result of the consultation. In fact, it
never said it would.
Well, that's not the way I read their original statement, it wasn't the way
Labour MPs read it, it wasn't the way founding father of disability rights Lord
Alf Morris read it, it wasn't the way the unions read it, it wasn't the way
social care charities read it and it wasn't the way Community Care readers read
it either.
That's why they wrote to the DCLG in their droves.
That might not have happened had Community Care not been the first media outlet
to publicise it.
Greg Clarke, minister for decentralisation, yesterday
acknowledged that media interest had heightened responses urging the government
not to cut the duties around adult or children's social care.
If I was being generous I might say the whole thing was simply a misunderstanding, crossed wires on the government's intentions. But part of being in government is being responsible. And if
you hastily put together and all-encompassing list of statutory duties and sell
it as an opportunity for people to get their least favourite whiped off the
statute book, you can't be surprised when people think you might actually do
it.
Thankfully, it looks unlikely to happen now as Clarke has acknowledged the
primacy of the Law Commission and Munro reviews in adults and children's social
care respectively.
You, readers, made that happen and I, for one, am proud to have been a part of
it.
Image by Ste
on Flickr
The Death Tax
If there's anything that symbolises the political classes' failure to reform care funding it is this Conservative poster from February 2010. It marked the breakdown of behind-the-scenes, talks on reforming care funding between the three main parties, initiated following the Labour government's July 2009 Green Paper on the issue.
The paper had proposed, among other options, a compulsory levy of £17,000 to £20,000 on all pensioners (bar the poorest) to fund a National Care Service for all in need. This levy could be paid by their estate in the form of an inheritance tax. Then health secretary Andy Burnham favoured such a levy and the Tories - scenting political gain - decided to go to war on the issue, with David Cameron bashing Gordon Brown on the issue in prime minister's questions.
The Tory strategy worked. Labour's White Paper, issued in March 2010, weeks before the election, backed a National Care Service, free at the point of need, but deferred any decision on how it would be paid for until after the subsequent election.
The resulting acrimony between the parties was significant. And the episode, probably, further enshrined in the public mind the myth that social care was already free (i.e. tax-funded) and that any suggestion that people's inheritances should be used to fund it was illegitimate.
Tony Blair's pledge to our children
By 2010, Labour's political capital was spent. But in 1997, with a massive majority, it had a much bigger opportunity to reform care funding. This was the year in which a young Tony Blair told the Labour conference: "I don't want [our children] brought up in a country where the only way pensioners can get long-term care is by selling their home."
The result was the Royal Commission on Long-Term Care for the Elderly, established to recommend a sustainable system of funding.
It reported in 1999. While a number of its recommendations were accepted, its headline proposal - for the taxpayer to pick up the bill for personal care for older people - was rejected by ministers (as well as being opposed by a minority of the commission).
The commission said personal care was a risk that should be covered by pooling, with general taxation the most efficient and fairest way to do so. But the government argued that its cost would be "substantial", while the reform would not help the least well-off who already received free care, nor improve services. The policy was implemented in Scotland, however, though its future affordability is now being questioned.
The Wanless report
Between the royal commission and the death tax row came an attempt from outside government to reform the care system: the King's Fund's 2005-6 inquiry led by statistician and banker Derek Wanless. Wanless came with great pedigree, having persuaded Brown and Blair to massively increase NHS funding (and raise national insurance in order to do so) with his 2002 report for government on the health service.
His social care report (March 2006) was well-received. Its key proposal was a partnership model of funding, in which the state would pay two-thirds of the costs of eligible people's personal care and then match fund the remainder of the cost with individuals (the poorest would have their full contribution met by the state).
Wanless believed his solution would be affordable, help those with moderate means who were excluded from state support and give everyone a stake in the social care system, ending its status as a "safety net for the poor". However, the Treasury quickly made clear that the proposal was too costly to win government support.
Ahead of the Dilnot report, the Treasury is indicating its hostility to expected proposals to increase the liability of the state by placing a cap on individual contributions to care. This suggests that the ghosts of these past failures are starting to stir from their graves.
About the Adult Care blog
The Adult Care blog looks behind the policies, practices and personalities involved in the care of older and disabled people for any hidden truths, helpful tips or humour. It is written by Community Care’s adults’ services beat editor Mithran Samuel. |
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