Fixing Care
Below is the response by the NPC Health & Social Care Working Party on the proposed plans for Care Services.
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Introduction:
This briefing is a response to the Prime Ministers statement on the ‘plan’ for Care Services in the House of Commons on 7th September 2021.
The historical background of care has always been a means-tested service delivered primarily through Local Authorities and private/equity funded provision. This is significantly different to the National Health Service (NHS) funded through taxation and publicly owned/accountable.
Successive governments, over the last two decades, made decisions on budgets and funding cuts to both the NHS and care services driving forward the privatisation and marketisation agenda inside the NHS and care provision. The most damaging of these is the Health & Social Care Act 2012 with Andrew Lansley as the Secretary of State (commonly known as the Lansley Bill), followed by the 2014 Care Act which, through lack of proper funding, never did what it was supposed to – improve care and the lives of carers.
Operation Cygnus in 2016 showed how cuts to funding in the NHS had adversely impacted on its ability to deal with emergencies like a pandemic. Decisions were made that bringing equipment and staffing up to the standard recommended would cost too much and therefore the Conservative government of the time continued slashing budgets and opening up the NHS to more tendering for contracts from private providers. We know the price we paid for that.
In terms of care, year on year cuts to Local Authority budgets, and changes in law, made it extremely difficult for them to continue to fund care in their own residential and home care settings to a high standard. Very few councils run care in-house, becoming commissioners of services instead of hands-on provision by staff employed on public sector contracts. The services commissioned in the private sector are themselves underfunded, with savings often made on the back of terms and conditions for staff. The crisis deepened and now Local Authorities are only able to care for those with substantial/critical health conditions. This means that 1.8 million people are not receiving the basic care they need, impacting on their health and well-being on a daily basis. There are also many situations where much of the care is provided by a low paid, undervalued and mostly unqualified workforce.
The NPC, health professionals and care home providers consistently raised the ongoing chronic under funding of care and the inevitable happened as the pandemic struck.
The Prime Minister was elected on a mandate of ‘fixing care for good’ and made a speech on the steps of 10 Downing Street in 2019. We have waited and waited; argued and argued for a better deal and hey presto a plan emerged on 7th September. Except it’s not really a plan, it is a vague description of caps and costs with nothing for carers, care workers and certainly not a plan to reform care in accordance with the needs of the who fund it deserve. The quality of care will still be relative to a person’s ability to pay for it. Therefore, equality of access is not addressed and the unfairness of funding care remains in place.
All of this is set against the backdrop of the NHS Reform Bill, which, if implemented in its present form, subsumes care into an ill-conceived model purported to protect the NHS with no specifically identified funding other than the proposed care levy. It also comes with the promise of yet another white paper at a future date despite having had 12 consultations and 5 reviews over the last 20 years – all of which changed nothing.
Current system v 2023 model:
Making sense of what will happen in 2023 is still a bit of a muddle in respect to the writings in the ‘plan’. It does not change the fundamental way in which people access care – it is still means-tested. It also does not change the fact that the ‘housing’ element of care home costs still have to be met by the individual and may require the sale of their home to pay those bills. Self-funders pay different rates to Local Authority which means in effect the cost is more and it subsidises the Local Authority rate.
There is also the unfairness of those suffering cancer receiving their care from the NHS free whilst those suffering dementia and other health conditions, are means-tested. It is not clear how the Prime Minister’s statement to make care more fair will operate.
Depending on your care package and where your care home is, here are some average costs.
How does the new system to be implemented in 2023 compare to the current means-tested method of today?
In England now:
· Assets less than £14,250: care is funded by the state, but depending on income, an individual may find themselves paying ‘housing’ costs if in a care/nursing home. Currently care homes can be paying as little as £2.15 for a day’s meals for a resident, but in reality housing/hotel costs applied often reflect a much higher sum being paid at the moment.
· Assets between £14,250 and £23,250: care is means-tested, and contributions made from assets accordingly.
· Assets over £23,250: care is self-funded.
· Many figures were proposed as a ‘cap’ on care ranging from £35,000 to £72,000 – this being the maximum anyone would pay in total for their care before the state took over payments. Just as the £72,000 cap was about to be introduced, the Conservative government abolished it in 2015.
In Scotland the assets level is £28,000; in Northern Ireland £23,500 and in Wales £50,000 for care home fees and £24,000 for home care.
Personal care (on assessment) is free in Scotland; home care is free for over-75’s in Northern Ireland; and Wales caps costs at £90 per week for home care services.
In 2023, the system changes to:
· Assets less than £20,000: care funded by the state.
· Assets between £20,000 and £100,000: care is self-funded with some state help after means-testing.
· Lifetime ‘cap’ on care costs: £86,000 (considerably more than the original proposal of £72,000 and less than Theresa May’s proposal of £100,000). We remind you that this is for the care element of costs only, other costs will still need to be paid but do not count towards the ‘cap’.
Assets include income, savings, value of your home if you own it, the contents of your home, stocks and shares, private income – literally anything that comes into your bank account.
Scotland, Wales and Northern Ireland are said to benefit by an extra £5.7 billion. It is not clear whether this is a total figure for each nation or whether some sort of sharing formula will be in place.
In terms of the £86,000 cap to be implemented in 2023, this is not back-dated, so any costs for care accrued at that point will not count.
The government will most likely increase the use of Deferred Payments Agreements. This is a system by which Local Authorities set up a ‘loan’ for individuals who own their own home to pay the cost of their care. It is means-tested and attracts interest and administration fees. The loan has to be repaid either at the point at which the home is sold or on the death of the individual. It is similar to ‘equity release’ schemes with the ‘loan’ no more than 90% of the market value of the home. However, should your home devalue over the time of the agreement, the agreement does not change in terms of paying back the loan. In effect, there is always the possibility that the value of the home at sale will not cover the costs of the agreement.
Carers/Care Workers:
The contribution made by the 5.4 million unpaid carers bridging the gap in care in the UK is valued at around £132 billion a year. Many carers are themselves in poor health, experience poverty along with the stressful responsibility of caring. There is little more than a vague promise from the Prime Minister to ‘take steps’ to help unpaid carers to get ‘support, advice and respite’. Under the Care Act, carers were entitled to an assessment in their own right (independent of the assessment for the person cared for) and offered a range of services intended to support physical and mental well-being. But, as usual the funding for this got lost along the way of funding cuts and just getting an assessment is, in many cases, a search into the unknown. So, the idea of recognising and respecting the huge army of people saving the government billions of pounds has largely been buried.
Carers Allowance at £67.60 per week is a paltry sum given the commitment to caring that the 5.4 million carers give every day. At the point at which an individual retires, the Carers Allowance is stopped if your pension income is above that rate. It is then a minefield of means-tested benefits and the stress that causes. Poverty is a feature in the lives of an overwhelming number of unpaid carers.
The vast majority of the 1.5 million care workers work for private companies and earn on average £8.50 an hour, though a great deal less than that if we take unpaid travelling time into account. There are currently 112,000 vacant care vacancies in England and nearly a third change jobs each year. This means continuity of care, especially important for those with dementia, is affected and the impact is instability in the care provision.
The £500 million earmarked for investing in the care workforce is spread over three years and works out at an extra £2 per week per care worker. However, this will not reach their pay packets, it is to go into measures that ‘support professional development and long term well-being’. Whatever that is, £2 per week per worker will not deliver sufficient remuneration to lift care workers out of poverty.
Funding:
From April 2022, an increase of 1.25% on National Insurance Contributions will come into effect. In reality, because of the way the system is structured, many MPs of all parties are raising concerns that the ordinary worker will be paying to protect the wealthy. It is another case of the poor subsiding the wealthy – this is the wrong way to fund care.
In 2023, the increase reverts to a ‘health and social care levy’ and includes those pensioners who continue to work. This is a concern for the NPC as the majority of pensioners continue working due to the state pension being inadequate and not enough to pay their bills.
The money on offer is less than you think. From the £36 billion the government say will come in through regressive taxation, only £5.4 billion with go into funding care. The £500 million set aside for ‘investing’ in the care workforce also comes out of this total. The rest goes to the NHS and the NPC genuinely believes that ‘integrated services’ will always give priority to the NHS. Those needing care will still be restricted to substantial or critical (if not just critical) on assessment.
The Kings Fund estimates that only about half of the £5.4 billion will go to fund care with the rest going towards replacing the money that people with assets will no longer contribute; i.e. they have reached the £86,000 threshold. All in all, around £2 billion a year falls a long way short of ‘fixing care’. It is not enough and the government know it.
There is no replacing the cuts of over £6 billion to care in England. There are no tangible thoughts in the paper in regard to equity funded private providers who extract huge sums of money from the taxpayer to off-shore accounts located in tax havens.
For example, HC1 – one of the larger equity funded providers – with a business model that has posted a loss every year since 2011 when it was set up. It has never paid corporation tax, but between 2017 and 2018, it still paid out at least £48 million in dividends to shareholders.
Conclusion:
After all the hype, instead of a reforming vision which includes prevention, independence and community services targeted to need (although we are assured that will come through the 42 Integrated Care Services/Boards), it was all about the money. And not enough of it.
Care homes were struggling before and during the pandemic and are still struggling now. Two years down the line, many of them may have closed. Some equity-funded providers have also closed homes, but we suspect that is more about profit loss than the day to day struggles that small and medium sized care homes contend with.
There is nothing about choice in the paper – something that the NPC has put at the heart of our policy for a National Care Service. A National Care Service which stands alone and is separately funded from the NHS funded from general taxation; i.e. redistribution of wealth will ensure that everyone needing care will choose how, when, where and who that care is provided. Preventative services, advocacy and support for unpaid carers is a key feature of ‘Goodbye Cinderella – A New Settlement for Care’, as is training for care workers/managers with a grade allied to NHS and a career structure that enables workers to progress and commit themselves to what is a most vital role in caring for those in need.
The government and their think tanks would have you believe that it is older people who are costing the country for care. Not true, the bulk of the care budget is spent on working age disabled people. Not that it matters because whoever needs care should be able to access it when they need it.
Equality of access and the quality of care provided will still be a feature and be relative to a person’s ability to pay for it. Means-testing remains and that has connotations for the plan to ‘merge’ the NHS and care (Sajid Javid – Guardian) with the NHS potentially forced down the means-testing route.
Bringing together two services that are differently funded will not work to anyone’s advantage.
The NPC will continue to promote its policy for a National Care Service, targeting the public to try to get them to understand exactly how paying for care works and that it is nothing like the NHS – free when you need it.
This briefing will be updated as we understand more about the ‘plan’.