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
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
“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
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
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
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
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
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
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