Most of us don’t like to think about the last years of our lives. If asked, we want to die peacefully in our own homes. Fewer than one in three do so. Forty percent die in noisy, busy hospitals. And government doesn’t like to think about it either. Caring for people in those years is expensive and paying for it is politically explosive. People don’t want to pay more for something they don’t want to think about.
Asked what issues are most important to them, a third of people put the NHS at the top: but only 4% say the same about social care. So there is little political pressure to act, and every attempt to find a way of paying for a system which delivers decent care is defeated by party politics. Endless inquiries and reports produce no action.
Meanwhile, half of all people with care needs get nothing (not even unpaid care from relatives or friends).
As the Kings Fund reports, we have a system which does not deliver what people need, is bankrupting local authorities, handicapping the NHS and failing to pay staff properly for what should be a skilled job.
Andy Burnham has been concerned about this since he was a Minister and Health Secretary in the Blair and Brown governments. Now he says it is a priority for his new government. So, what are the issues and what are the options?
Uncertainty
The first problem is unpredictability. Whether I will need care in later life and how much, is entirely unpredictable. Most of us will live to around 80, some much longer. Some will remain fit and healthy and die in their own homes with minimal support. Others will need care, for weeks or for decades, in their own homes or in a residential setting. For one in seven, the cost will be greater than £100,000 and people are expected to pay those costs until their assets fall below £23,250. This comes as a distressing surprise to many people and their families.
The classic solution to this sort of dilemma is some form of insurance. We all pay a modest amount into a pool, in return for a guarantee of support if we are one of the unlucky ones. We accept the principle through taxation for the NHS and privately for house insurance: we could for social care.
Not enough money
The second problem is that current funding is inadequate. Local authorities spend around £11bn on care for people over 65 and the law requires them to provide it for everyone whose income falls below the threshold.
But as the population ages, the numbers are bound to rise, especially in coastal areas like North Norfolk (the oldest district in England). Because this is a statutory duty, councils with fixed budgets can only pay for it by cutting other, more visible and politically sensitive ‘discretionary’ services like refuse collection, libraries and roads. As a result, despite often heroic efforts by staff, the quality of care is often less than we would want in our final years,
None of the options to balance the books is painless. Local authorities can tighten the entitlements, but they already reject a third of all requests for care. If they pay less to the private providers who deliver most of the care, that gets passed on in poor wages for staff and lower quality of service. And if the price falls below a certain point, nobody will be willing to provide the service.
Finally, at any one time there are around 3,000 people in hospital who are medically fit for discharge but who are unable to leave because they need social care which is not available in the community. This is hugely wasteful: a hospital bed (with all the associated costs) costs three times as much as a residential care place, and every one of those beds is an NHS patient in a queue waiting for treatment.
Andy’s options
So, individuals need some protection from the risk of facing large and unpredictable costs while the whole system needs more money. Louise Casey’s current review is due to report ‘before the 2029 election’: a recipe for further inaction.
But the options are clear.
1. Pay more through general taxes. More of the costs could be added to general taxation, which is how we fund the NHS. This is simple and the risk of needing care, like the risk of falling ill, is shared. But, to do it would require raising one of the major taxes and people rarely vote for more taxes, especially on something that most of them have no immediate experience of.
2. Introduce an insurance‑style system. Individuals and/or employers would pay into a social care insurance scheme (public or private). The policy would then cover some or all care costs if they need support later on. This spreads risk over time and across the population, but is complex to set up and there are hard questions about when to start, what to do about older people now and how much is compulsory.
3. Change the balance between individual and state payments. The total sum an individual could be asked to contribute towards social care costs over a lifetime could be capped. This would protect everyone from catastrophic costs. The excess might have to be raised by additional taxation.
4. Limit state funding to ‘care’ costs. This would leave individuals to continue to pay the costs of food, accommodation, utilities etc. This was a core part of Sir Andrew Dilnot’s 2011 report.
5. Rely more on local taxes and charges. Local authorities could be allowed to raise council tax or business rates to spend more on social care. This would make accountability more visible and local, but would mean a ‘postcode lottery’ with poorer areas having poorer services.
7. Pool health and care money. If health and care were both paid for from the same budget there could be savings from better coordination. It would also end the absurdity that someone with cancer gets treatment free on the NHS, while someone with dementia, or who is just not able to look after themselves, has to meet the cost themselves. This can improve coordination and reduce waste, but does not remove the basic choice: the combined pot still needs more money, more rationing, or both. And the history of the NHS shows that more funding usually ends up in expensive hospital treatments, not prevention or primary care.
It seems likely that Andy Burnham will press Louise Casey to bring forward the report commissioned by Keir Starmer. Burnham says that he wants a more cross-party approach to questions like this. It would require the major parties to agree not to use this to attack each other.
It is what we need, but will they have the courage?
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