It's time for a grown up debate about how we pay for care

Many have been wondering whether the landmark report on adult social care Power to People will be acted upon or, with no government, left on a shelf.

This week we have our answer which was delivered by Sean Holland, Chief Social Work Officer at the NICON conference in Belfast. And it is good news – it will not be gathering dust.

Power to People is a companion report to the equally crucial Bengoa report into the health service. It is a truly radical paper which describes the current system as collapsing in slow motion and proposes 16 measures to make it fit for purpose in the 21^st Century.

We have provided a summary of it here .

What seems significant about it is that civil servants recognise that the issues are sufficiently important and urgent for it to be progressed even in the absence of Ministers. There is nothing to stop them from developing policy positions, but it is a difficult, complex, and in places, politically sensitive area.

Publication was delayed for several months. It had been commissioned by a Minister and it would therefore have been preferable if it were to have been delivered to one. Holland explained that this was put back week by week for that purpose but by the point was reached when there had been no government for a year, it was felt publication could not be delayed any further. This happened in December last. This showed courage.

There were fears that this was where the matter would rest until such time as a government would be reformed and that therefore there would be further delays in the reform process. Risks are mounting. The report could not be blunter: “fundamental reform of adult care and support is required to avoid a total collapse of the system with all the implications this would have for those in need.”

Ultimately a Minister will need to be in place to implement changes and to introduce legislation to a functioning Assembly, where this is relevant. But in the meantime the department can prepare the ground, developing the policies for approval. The fact that it is doing exactly that is much to the department’s credit.

Power to People criticises the way that the market operates for both residential and domiciliary care. It states that this has become a race to the bottom, with the commissioning regime forcing down rates paid to independent providers. This has the inevitable consequence that staff in the sector are poorly paid.

It argues for the Trusts to work with providers to establish the true cost of care, based on providing a reasonable margin and for staff to be properly compensated for the difficult and important work that they do.  To ensure public confidence in the system there should also be price regulation.

This will help to ensure a fairer and better system. But it will also means that it will cost more – and in the future we can expect demand to rise and not fall.

This is precisely why a full, honest public debate is required. And the debate needs to get underway immediately, it cannot be just for politicians to decide.

It needs to start from the shared understanding that no public services are free. Health services may be  “free at the point of delivery” but we all have to pay for them through our taxes. Social Care is different. Residents of care homes are means tested to determine whether they should contribute to costs. And older people who are below the threshold still effectively pay because their pension would go to the home, along with any other relevant benefits: they are paid back small amounts for their spending money.

So as health and social care costs rise, how do we, as a society intend to fund them?

One such issue is raised in the report. Whilst residential care is means tested, domiciliary care is not. It’s free for everyone. Why? This is an important issue because so long as people who can afford such services but don’t pay for them, everyone else will have to pitch in and other services which might otherwise be funded are not provided.

There are much broader issues too. The population is ageing, with more and more people no longer working. This in turn means that the tax burden gets larger for those who are in work. Fertility rates are falling so there are less of them and post Brexit there will be fewer immigrants joining the workforce to take up the slack. We have seen rises in pensionable age in an attempt to offset this, should these go up still further?

These are precisely the sort of difficult issues that politicians least like to talk about. And when they do, they rapidly turn toxic.

In Britain both main parties have seen policy initiatives designed to address this collapse.

Back in 2010 the then Health Secretary Andy Burnham was wanting to establish a National Care System in tandem with the NHS. One of the options laid out in a Green Paper examining this was the notion that people would pay 10% of their estates when they died to the state, in exchange for free social care during their lifetime. Attempts were made to establish an all-party consensus on this. This broke down – the Conservatives spotted an electoral opportunity. They dubbed it the “Death Tax” and Death Tax posters featured prominently in the election campaign. Labour lost.

The Tories fared even worse in 2017 when they proposed that the cost of care should be deducted from peoples’ assets when they died. Labour, presumably itching for vengeance, dubbed this the “Dementia Tax” – and this became a major issue in the subsequent election which left the Tories as a minority government. Needless to say this initiative has disappeared without trace. The problem can and should be resolved, but there is no appetite for the necessary political consensus.

The trouble with politicians is that they will always put short term electoral advantage over working together to solve long term strategic issues. The result is that crises we forsee long in advance fester and worsen. So much better therefore to promote informed public debate so that we can examine choices carefully, debate them and work through the best ways to resolve them – after all we are all going to end up paying one way or another. It’s not free.

This brings us to a puzzling aspect of Power to People and to the subsequent departmental response. The report states: “It had been intended that alongside our review and the development of proposals, separate work would be commissioned to get an expert view on the cost of implementing various proposals. Although we have had the benefit of some systems analysis as a means of exploring the impact of the proposals, no detailed financial modelling has been undertaken. “

Presumably this will be addressed at some point – new policies will need numbers attached to them. It’s just a pity it is not available at a time when the department will be wanting people to contribute to developing the exciting ideas in the report. 

Of course the debate about the future of adult care is about much, much more than cost. Yet we all want as much as we can out of the system that every single one of us will, at one time or another be in need of.

But unless we spell out the choices in monetary terms the debate will be skewed and may build unrealistic expectations.. This is just the way of things. It is why we simultaneously want free prescription charges, free home care, no death or dementia taxes and somehow think this is possible to achieve without increasing income tax. There’s a price for all of these, the crux of the matter is not whether we pay, but who pays for it and how.