The colour of money: Dilnot and the social care White Paper

Reading the runes of an imminent government White Paper used to be straightforward. Some months before there would have been a Green Paper, setting out the government’s broad thinking and consulting on key options. The subsequent White Paper would set out firmed-up proposals as a prelude to draft legislation. However the Equity and Excellence: Liberating the NHS White Paper turned that on its head, with consultation papers published afterwards and then the pause and listening exercise.

In contrast, many hope that the forthcoming care and support White Paper will not require a colour chart to detect more than a hint of green. Unlike the NHS reforms, there is universal consensus that the social care system is not fit for purpose and requires radical reform – which is not the same as reorganisation. The NHS will never work properly without it.

Much of the policy groundwork has been done, with the Law Commission’s proposals for a major legislative overhaul as a potential centrepiece, and a clear sense of purpose arising from the Department of Health’s engagement exercise last autumn. Much of this is relatively uncontroversial politically and everyone in the care sector supports change. It is the final piece of the jigsaw – Andrew Dilnot’s report on how care is funded – that was always going to be the trickiest to lever into place.

From the outset the government said it would publish its response to the Dilnot report as a separate ‘progress’ report and not as part of the White Paper itself. Since then, the economic climate has worsened, media coverage of concerns about the quality of care has proliferated and real terms spending on the care of older people is falling. A key challenge for government is balancing the demands of an underfunded system whilst protecting people from catastrophic care costs. This has got so much harder since that confident declaration in the government’s programme nearly two years ago when it recognised ’the urgency of reforming the system of social care’.

The balancing act the government now needs to pull off is similar to that facing the Blair government in 1999 when another independent commission recommended free personal care funded through taxation. It chose instead to pump extra money into the publicly funded system and introduce an element of ‘free’ nursing care. Then the economic sun was shining but this government has fewer choices about how it can balance these trade-offs. Cross-party talks are continuing and the next spending review will be the ultimate crucible in which social care takes its chances against other competing demands for diminishing public finance. The political mood music does not inspire confidence that social care has made it on to the ‘must-do’ list of government priorities, although it touches the lives of at least 10 million people – a quarter of the adult population of England.

A White Paper with positive proposals that could form a good story about the reform of delivery will be warmly welcomed. It would kick-start some serious implementation work in areas like information and advice, assessment and integrated care. Even if it has a greenish tinge, which seems likely in view of the scale of what needs to be done, a clear commitment to action should ensure that this aspect of care reform will avoid the tortuous and troubled trajectory of the Health and Social Care Bill. But it will need legislation, and the omission of a social care bill from the Queen’s Speech will cause disquiet. Further delay in tackling the reform of funding – an essential accompaniment to reform of delivery – will be greeted with deep dismay and disappointment.

In the absence of an unequivocal acceptance of the Dilnot framework, Kremlinologists will be busy subjecting the words of the government’s separate report on funding to forensic scrutiny. So the biggest question when both documents are published will not be about the colour of the government’s White Paper but the colour of its money.

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#1161 Peter Robey

Very impressive

#1162 Richard Pantlin
Social care consultant
Richard Pantlin Ltd

All very true. Question is how any government tackles such a long term problem when there are no easy votes without substantial extra cash and media will always pick on the problems with any change ...

#1163 Lynne Livsey

The big risk is that we end up with yet another consultation on the different models that might be used to fund social care. We've had Wanless, JRF and Dilnot all recommending the partnership model ...yet no action. Public attitude surveys appear to confirm public support for using taxation to fund long-term care (but this would have to be ring fenced). Yet, it seems, no-one will provide the figures for public debate about whether a tax-funded model might be a realistic possibility. It is very frustrating for everyone trying to second-guess what might happen in such a prolonged policy vacuum.

#1164 Chloe Carter

Unless I've missed it in the recent flurry of literature, I still haven't seen anything solid from the Treasury. There have been indications that other Departments and agencies are engaging with the partnership model, but the Treasury have been concerningly quiet.

#1165 Margaret Dangoor

In May 2008 I was paying £168.86 monthly for my husband's care at a high dependency day centre for people with dementia. Now in May 2012 I am paying £1356,34 at the same centre for the same amount of hours. My husband attends the centre because it is therapeutically of benefit to him as he continues on the downward path of the dementia journey. The centre provides him with security and socialising and activity within his confusion. However, 8 hrs day care still leaves significant unpaid or paid care care to be provided day and night. The cost of my mother's care, in a nursing home, she is nearing 102 yrs, is now nearing £350,000 but in reality, the hourly rate for my mother's complete care is less than that provided at the day centre. This is the reality of care today. A significant percentage of older people are as we know self-funders who, often suffering from dementia, have carers who provide many hrs of unpaid care in addition to any self-funded support they purchase. As a chair of an 'Experts by experience group' of carers of people with dementia, I hear worrying stories of carers coping (or not coping) with their responsibilities, both personal for the cared for person and in running the affairs of both parties. Financial worries and access to care are relentless concerns, particularly as they are open-ended. On the other hand, I am, even as a carer myself, constantly uplifted by the efforts that the carers put in to providing the best possible support to the cared-for partner. One of the most depressing and recurring thoughts for carers is that they do not wish to burden their own families with their own care in the future; they recognise so well the comprehensive commitment and let's be honest, the sacrifice required. Whilst accepting these are difficult financial times, there is a view that older people are being treated as 'cash cows'. If you can't do it yourself; then pay for it and feel lucky whilst you can pay for it. The estimated figure as to how much carers save the country in relation to unpaid care provided is well known; carers are making their contribution and somehow that contribution has to be better supported by reassurance concerning all the political parties' commitment to finding a way through the issue of future funding. This issue must be addressed however moderate the practical commitment is decided upon; once a modest financial model of support is approved, it can be uplifted in better times. At least it would begin to create a change of culture moving towards the fairer funding of social care and certainly be of psychological benefit to carers and the cared for.

#1166 Mike Nicholls

We have to reach a conclusion. Over 8 years ago, when I was a the county council member for social care I wrote a paper "Not so much a crisis more a way of life". At that time the trends were clear and yet nothing that has happened subsequently has made any significant progress..

Whilst the integration of Health and Social Care is of utmost importance it is not a panacea. The current system of eligibility criteria has turned social care largely into a crisis intervention service.
When carers in their late seventies and eighties often themselves suffering from the chronic health problems of old age, cannot be offered practical hands on support, but only "advice", or the stark choice of their loved one loved one going into residential care. Enough is enough, we are shortening the lives of both carers and those for whom. they care. Has this country lost all compassion?

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