Shaping the Future of Care Together

Response

Dept of Health Consultation:

Shaping the Future of Care Together

November 2009

Carers: supporting the bedrock of social care

The Secretary of State for Health announced that carers are the bedrock of the care and support system. However, the Green Paper[i] has not attempted to create a National Care Service that recognises their central role. The claim that “by improving support to people who need care, we will also be supporting carers” [ii] is correct, but does not address the needs of those thousands of carers who will continue to contribute a greater amount to their relative or friend’s care than the State.

The Green Paper focuses on the financial contributions needed to create a sustainable social care system without considering the in-kind contribution provided by carers, which is of far greater value than the potential cash contributions released by the proposed funding models.[iii]We have produced a report, Crediting Carers: Building society to care, recommending a credits for caring system that would encourage and sustain people providing care. This report should be read in accompaniment to this response.

Creating a National Care Service

We have found overwhelming support for the introduction of a national assessment and national eligibility criteria. 80% of respondents to our survey supported a national set of eligibility criteria, although there were comments that the national government should not set these.88% supported a national assessment that could be taken to any local authority in England.

There has been a smaller majority of people supporting a national setting of services or personal budgets to meet assessed needs, with 66% supporting that option. Fairness and reducing disparity among local authority areas were the main reasons for supporting this option. However, there were also concerns that such a system would restrict flexibility and lead to inappropriate services and service levels being provided.

The creation of personal budgets does allow greater standardisation among local authorities in terms of service level response to assessed needs. ADASS have published a Common Resource Allocation Framework that attempts to provide a Resource Allocation System (RAS) that all local authorities can use[iv]. The score calculated produces an indicative value for the personal budget. If a national assessment and eligibility criteria was created, a national RAS could be created to match needs with a personal budget value. Allowances could be included that account for greater unit costs of care, such as in London or in rural areas.

Alternatively, a national RAS could produce an indicative value that the Local Authority use as a guide but can amend as to fit circumstances. This would effectively create a part national-local system described in the Green Paper.

It would appear more difficult to create a national system that assigns services to assessed needs where the individual preferred a social care package to a personal budget, as it would be impossible to create a national set of service packages that equate to every possible assessment of need. The availability of services also depends, partly at least, on commissioning and core funding of these services. We believe that good commissioning can best be achieved with the involvement of users, carers, local groups representing them and providers of services, which would therefore require commissioning to happen at the local level rather than the national level.

Considering this, we support the combination of a national assessment; national eligibility criteria; a national RAS that produces indicative budgets but with local flexibility; and local commissioning of services. This in effect creates a part national-local system.

Supporting joint working

In our survey, we asked which of the six principles proposed for a National Care Service wouldrequire most work to make a reality. Creating services that are joined up was the most commonly identified – 69% of respondents.

During the consultation we proposed an idea that families where there are multiple people receiving a personal budget or a service could have the option to create a whole family support plan or budget. 92% of people agreed with this proposal. This would bring together various agencies into a co-ordinated plan, although would only be considered with the individual consent of all who were assessed. Assessments would still be individually completed as the carer, and the person receiving care, may feel inhibited if speaking in front of other family members.

The principle of pooling budgets from various people, could also apply to the pooling of various budgets received by one person. For instance, personal health budgets could be pooled with social care budgets to enable the user to manage them as a single budget.

The Green Paper proposed the integration of benefits with social care; however we would only support integration at the individual level so that the choice to combine the welfare benefit and the personal budget could only be made by the individual. 58% of respondents to our survey would support such an option. We outline our opposition to the Green Paper proposal of integration of benefits and social care budgets at the national level below.

The Princess Royal Trust for Carers is currently managing a project to improve joint working between health and social care in Scotland. The Moffat Programme is a collaboration with nine Carers’ Centres, four local NHS health board areas and 10 local authorities. This programme aims to improve hospital discharges by identifying carers and ensuring that they have the information and support to help them provide care at home.

For instance, in West Lothian, the Carers’ Centre works closely with all members of multi-disciplinary health and social care discharge planning teams and in the Borders they have developed a discharge checklist to confirm that they have gone through everything with the carer. The Carers’ Centre in Edinburgh has created a referral system with hospitals to ensure that support is seamless when the patient is discharged home and the role of supporting cares is discussed as part of the Care Commission annual inspection. Having nominated leads within hospitals has proved to be an effective way to increase coordination and joint planning.

Joined up working such as this can also prevent needs increasing or presenting, which is an aim of the proposed National Care Service. Experience shows that rates of carer recognition within health and social care settings rise dramatically when they work with a core funded specialist carers’ service. One of the most successful examples ofthis is the Carers’ Centre covering Harrogate and Craven, whichcollected information on the annual rates of carer identification in practices working in various kinds of partnership with them.

The table below illustrates the marked difference in carer recognition depending on joint working.[v]Successful early identification of this kind has the potential to recognise people at risk and reduce health inequalities for both carers and those they care for and thus maximise carers’ sustainable contributions to care and support.

A partnership between the Royal Liverpool and BroadgreenHospital and Crossroads Care supports the stroke re-enablement project aimed to reduce the number of stroke re-admissions to hospital. Social care staff are integrated with staff in health settings and the specialist Crossroads Care staff are a part of the discharge team.

A barrier to joint working is that many of the issues included in the third tier of NHS Vital Signs are those that would require collaborative work amongst various health, social care or Third Sector agencies, whilst those that the NHS can achieve alone are in Tiers 1 and 2 of Vital Signs and it is these tiers that are more important in terms of performance assessment. This results in many of the problems experienced by carers being frequently due to a lack of co-ordination between various professionals/organisations, often at the point where care transfers from the NHS to social care. When there is integration, improved outcomes for carers and patients can result. To encourage joint working to improve social care, the Department of Health may consider restructuring what is in Tier 3 of NHS Vital Signs. In Scotland, key workstreams are looking at how reduced emergency admissions can free up money that can be used in local social care provision.

The funding options proposed could also affect successful joint working, especially between health and social care. A senior official in the NHS Confederation and a former Chief Executive of a PCT eachindependently advised that the comprehensive model would promote integration of health and social care, as both would become free at the point of need. This would enable health and social care teams to plan without the uncertainty of means testing for certain services.

Funding the social care system

We think that it was a mistake for the Government to rule out funding social care through general taxation as it meant that part of the debate was focussed on whether that option should have been included or not, rather than what the relative merits or demerits of that option are. It also implies that, despite rhetoric, social care is not regarded as equal to health care in importance or they would both be treated similarly in terms of taxation and public funding.

The Comprehensive model was more popular than the insurance model and appeared to be the most favoured throughout our consultation, although there was not a consensus on the best model.

We think that there could be problems with the Partnership model in a part national-local system where national government is committed to paying a percentage of the person’s care costs, but it is the local authorities that would assess needs and decide what the total cost of meeting those needs through services or a package would be. This would mean decisions taken by local authorities would decide the absolute value of the national government’s contribution, removing elements of budget control from national government.

National government could decide to give local authorities a set budget from which all national government contributions would be taken from, which if is inadequate to cover what is assessed could lead local authorities to under assess needs or the level of provision needed to meet those needs. This would increase pressure on families and friends to provide more informal care. Our accompanying report Crediting Carers: Building society to care addresses how carers can be supported in their caring role when providing more care but the issue of inadequate funding must be addressed in parallel.

We do not think that the Insurance model as proposed would have any effect in addressing the problems. As the Green Paper argues, voluntary purchase would be relatively small meaning a relatively high price of premium, which would further restrict voluntary purchase. However, we think that State encouragement and assistance to purchase insurance or create savings funds to cover the costs of social care should be explored and researched. Canada recently established a Registered Disability Savings Plan (RDSP) available through financial institutions that any individual eligible for the Disability Tax Credit may take out[vi]. Tax free contributions can be made by the individual, relative or friend up to a lifetime contribution lifetime of $200,000.

The Canada Disability Savings Grant provides federal contribution:

• When annual net income is less than $77,664 the grant will contribute $3 for every $1 contributed on the first $500; and $2 for every $1 contributed on the next $1,000.
• When annual net income is over $77,664, the grant will contribute $1 for every $1 contributed up to $1,000.
• The Grant can be received up to a maximum of $70,000 or up until the end of the year the person turns 49.
• Where annual net income is $21,816 or less, a savings bond will provide $1000 p/a without any contribution up to a maximum of $20,000 or until the person turns 49.

Canadian research projected that private contributions would equal four times the annual revenue costs to their federal government[vii].

During our consultation, we heard comments that the Comprehensive model including a mandatory paymentis very like a tax. However, we do think that a system where social care is free at the point of need is a great improvement, and as alluded to earlier, could promote greater integration with health care.

The Impact Assessment of the Green Paper considers the future supply of care, but does not consider the future supply of unpaid care in these considerations. Instead, Rafael Wittenberg, who performed the financial modelling for the Green Paper, advises that his modelling assumes an increase in the amount of care provided by carers rising in parallel with the provision of paid care, without any evidence that this will happen.[viii]Indeed, both the comprehensive and insurance model could diminish the willingness of family and friends to provide care, as theymight feel that all social care needs should be met as a result of the insurance payments they will have made.

Regarding the comprehensive model, our surveys have found that 69% support the option of paying a mandatory contribution from the estate after death. There have been concerns of free-loading where people deliberately spend or transfer savings so that there is nothing left in their estate to make the payment. We note that the Green Paper explains that some local authorities currently allow payment for accommodation costs from a person’s estate and it would be instructive to know if there have been frequent instances of deliberate asset reduction before death to avoid paying accrued liabilities.

Integration of benefits and social care

There has been overwhelming opposition to the integration of disability benefits with social care budgets during our consultation with Carers’ Centres, Crossroads Care schemes and via our online discussion forums and surveys.We also received many enquiries from people in Scotland, Wales and Northern Ireland who were worried that they could lose their benefits because of reform to the English social care system and how this would impact upon the devolved issues.

Currently, a person who has an informal carer receives a lower social care package or personal budget than somebody of identical needs who does not have a carer. Therefore, a family who provides care would not receive an equivalent increase in support from social services compared to the value of the welfare benefit. Whilst we acknowledge that the Green Paper states people currently receiving the benefit would be no worse off under the future system, people with a friend or relative who provides care and enters the system after the change would be effective losers.

The proposal also ignores the reality that many families use welfare benefits such as Attendance Allowance on necessary expenditure such as mortgages, rent, food and heating, which are items that personal budgets could not be used for. The ability to pay your mortgage or eat properly is as vital to health and quality of life outcomes as is the provider of care that you choose to purchase from. The proposal seems contrary to the Government’s Putting People First programme aiming to increase individual choice and control and therefore we oppose the proposals.

Many carers were also worried that what the passport process would be for carers to qualify for Carer’s Allowance if Attendance Allowance did not exist. Likewise, carers were unclear how a single national assessment would affect the carer’s assessment, if it all. The absence of recognition or comment on potential effects on carers in terms of some proposals in the Green Paper was a recurrent theme, which led to fear and conjecture which attracted debate and focus away from other proposals.

References

1

[i] Shaping the Future of Care Together, Dept of Health, 2009

[ii] Pg. 20, Shaping the Future of Care Together, Dept of Health, 2009

[iii]Just Care, IPPR, 2008 calculated that it would cost £67bn to replace the care provided by carers and Valuing Carers: calculating the value of unpaid care, Carers UK, 2007 calculated that it would cost £87bn

[iv]

[v] Pg. 24, Putting People First without putting carers second, The Princess Royal Trust for Carers & Crossroads Care, 2009

[vi]

[vii] Pg 26, Disability Savings Plan:Contribution Estimates and Policy Issues, K. Horner, 2005

[viii] Health Select Committee, Social Inquiry, Oral Evidence, 5th November 2009

For more information:

Gordon Conochie: / 07766 410885

Joint Policy & Parliamentary Officer

The Princess Royal Trust for Carers and Crossroads Care

About The Princess Royal Trust for Carers and Crossroads Care

We are the two biggest providers of services for carers in the UK and work together at a nationallevel to promote policies and guidance that will support carers.

The Princess Royal Trust for Carers is the largest provider of comprehensive carers supportservices in the UK. Through its unique network of 144 independently managed Carers’ Centres, 85 young carers’ services and interactive websites ( and The Trust currently provides quality information, advice and support services to around 354,000 carers, including 20,000 young carers.

Each Carers’ Centre within the network is an independent charity in its own right, delivering a wide range of local support services to meet the needs of carers in their own communities. Each provides expertise specific to their particular area of the UK. Carers' Centres’ core services include: