Who pays for care and who cares for the carers?

Friends Trustee John Austin reflects on the recent Budget

Who pays for care and who cares for the carers? These questions have been hotly debated over the past 20 years, but after successive reports, Green Papers, White Papers, Independent Inquiries and a Royal Commission are we any nearer a sustainable solution?

After years of cuts and increasing demand it would be churlish not to welcome the additional funding promised for the NHS and social care reflecting the overwhelming public support for the NHS, but is this another one-off fix?

In 2005, the House of Commons Health Select Committee* estimated that one in three women and one in five men would eventually require long term residential care.  In the past much care was provided in NHS community hospitals. but this has dwindled, enabling more people to be cared for in the community or their own homes. What should have been a positive change has resulted in increasing numbers of people, previously entitled to free NHS care, being cared for in private, fee-paying residential or nursing homes, or contributing to home-care costs.  How care should be funded is a contentious issue. Artificial barriers between health and social care lie at the heart of the problem of access to services, with complex procedures and widespread variations across the country.

The system should encourage care providers to help increase and maintain patients’ independence and provide support and respite for the thousands of unpaid informal carers,   but increasing numbers who need help with daily activities such as washing, dressing and eating may not be eligible for free services as their care is deemed to be ‘social’, with means-tested support being provided by local councils. The distinction between ‘health’ and ‘social’ care is blurred.  Successive Health Committee reports and the Royal Commission on Long Term Care suggested distinguishing between living/housing costs and personal care costs.  They recommended that all nursing care, and all personal care (defined as that which involves touching the patient – e.g. feeding, washing and dressing) should be provided free from general taxation.

In evidence to the Health Committee in 1998, Frank Dobson, then Secretary of State for Health, was asked to give a definition of the division between health and social care and responded that he could not.  A decade later, senior officials from health authorities, primary care trusts and local authorities working at the interface of health and social care were similarly unable to supply a definition. The Government argued that ‘the structure does not much matter’ saying ‘it comes down to how closely social care and health professionals are working together and how well they understand each other’s needs’.

Local councils and health providers are working together to deliver an integrated service but it is foolish to ignore the historic underfunding of community care services which has worsened with the cuts in funding for local authorities.

Earlier this year the House of Commons Health and Social Care Committee (HSC) reported that ‘since 2010, local authorities have had to cope with a 49.1% real terms reduction in the core grant they receive from central government,  a 28.6% real-terms reduction in their ‘spending power’.  They estimated real terms expenditure on adult social care fell by almost £1 billion since 2010.

Reductions have slowed as a result of additional short-term funding and allowing local authorities to raise more funds through Council Tax, but councils have only been able to protect their social care budgets by spending less on other services. The HSC estimates that local councils have reduced spending on social care by 3.3% in real terms compared to reductions of 52.8%, 45.6% and 37.1% on planning and development, housing services, and highways and transport.

In Brighton and Hove, the council has protected the care budget. Despite a loss in general funding of £33 million since 2015, the council has tried to protect vulnerable people by increasing the social care budget annually.  40% of the 2018/19 General Revenue Account is going to Adult Social Care, but there is a significant impact on other services.  Demand for social care is increasing, both in volume and complexity of needs, against a background of increased responsibilities under the Care Act, NHS cut-backs and a fragile care market that struggles to recruit and retain staff.

As a result, local authorities provide care and support to fewer people, concentrating on those with the highest levels of need. The number of people receiving publicly funded care fell by 400,000 between 2010 and 2016, and an estimated 1.2 million older people now have unmet care needs. The additional £650 million announced in the November 2018 budget is welcome. but this is between a third and half of the amount needed to fill existing gaps in services. 

£650m won’t be enough to plug current gaps, let alone bring back the care homes and home care packages lost over the last decade. 1.4 million older people with some level of unmet need for care will continue to make do without it, whilst older and disabled people lucky enough to be receiving any service are unlikely to see an improvement in 2019.

(*John Austin is a former Labour MP 1992-2010 and was a member of the Health Select Committee 1994-2005)

About the author

John Austin is a former Labour MP 1992-2010, was a member of the Health Select Committee 1994-2005 and is now a Friends Trustee.

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