Disappointing Government response to Dilnot - the long grass beckons!

by Dr. Ros Altmann

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No White Paper next year - just a 'progress report'!

Government right to focus on improving delivery of care but Dilnot's Working Groups should not be delayed

Following all the hype around Andrew Dilnot's long-awaited reform proposals for the funding of long-term care, it seems that the Government has unfortunately decided it is in no hurry to address this issue.

No sense of urgency on funding: Andrew Lansley's response in the Commons was a classic example of expectation deflation. Having publicly committed to tackling this issue urgently, having asked Dilnot's Commission to suggest how the funding of long-term care could be reformed, and having heard the report welcomed by all parties, the Secretary of State promptly squashed hopes of any imminent action. He said he would be using 'Andrew Dilnot's report as a basis for engagement and as a key part of the broader picture'.

No White Paper, just a 'progress report' in 2012: The Government surprisingly said there will be no White Paper on Dilnot even next Spring! Originally, it was hoped that there would be a White Paper by December 2011 and legislation following in 2012. This is not going to happen. If you look at the remarks in the Commons, Andrew Lansley is now saying that the Dilnot report is only one small part of the overall picture of social care reform, that it needs to be considered carefully, that it will be looked at in connection with the recent report on Palliative Care and that Government wants to increase personalisation and choice, rather than emphasising funding.

Reform of funding is urgent, but would cost money, so Treasury not in a rush! Perhaps it should not be such a surprise that the Government is backtracking on its promises of dealing with this issue urgently. As Andrew Dilnot says, he cannot imagine a system in which the Government spends less money than now, so the Treasury is achieving significant savings by not accepting reforms. Of course those savings to the Treasury are coming at the expense of those needing care, whose funding is being cut or who are losing all their lifetime assets due to the draconian means-testing system we have in place. The big problem, of course, is that people cannot plan properly to prepare for care and, without a reform of the funding framework, they will not be able to do so in future either. With our ageing population, this is a serious social concern and, ultimately, risks placing heavy burdens on future taxpayers to find money that could have been saved or provided by insurance from private sector sources.

Sleepwalking into a care crisis, following on from the pensions crisis: The number of people over 85 will double in the next ten years, the numbers needing care will rise by over 1.5million and yet no money is being set aside to pay for this. Having watched the pensions crisis develop over many years and seeing Governments putting off the need to help people prepare for pensions, it is frustrating to see politicians yet again dealing with vital long-term reforms from a short-term viewpoint. Such thinking led to our pensions crisis today, with many facing inadequate old age income. But, at least with pensions, there are already billions of pounds being managed in the private sector in people's pension savings. This may not be enough, but it is at least something. When it comes to care, however, there is nothing. There are no private sector products that allow people to plan ahead properly. Dilnot's solution of introducing a cap on personal contributions would allow the private savings and insurance industry to get involved.

Dilnot plans would improve both supply and demand for care planning products. Dilnot proposes that we need to pool risks in order to help plan for care. With health, there is national pooling via the NHS, with your house or car, there is pooling among your insurance company's customers, but with care there is no pooling available. Government wants an insurance market to develop, but the current system makes that impossible.

Dilnot proposes a giant national insurance scheme, with a £35,000 excess for each person who makes a claim, with the state picking up the rest of the cost above that. Plus extended means-testing threshold Dilnot's recommendations are certainly not perfect and the level of the cap, or the increased means-testing threshold may be too generous, however the thrust of his ideas is absolutely right. The current system is falling apart at the seams and needs to be addressed now, in order to help people prepare for care.

Government's extra resources are not ring-fenced for care Andrew Lansley has emphasised that the Government has already set aside another £2billion for care, which he says should ensure services are not cut. This claim does not stand up to scrutiny. The extra money is not ring-fenced, so it is not even being spent on care. While Ministers say that care services will not be cut, they are being slashed across the country. Local authorities are reducing their care spending, the numbers in need of care, who don't receive any help, are rising and standards are slipping.

Dilnot focuses on funding, but Government is focusing on delivery - they are not mutually exclusive! Andrew Lansley says he will be consulting widely on Dilnot's proposals and will issue a 'progress report' next Spring - that is far too slow. Dilnot has ideas that can be taken forward immediately. Whether or not funding reform is agreed, the parameters for change can be worked on straight away.

Dilnots' recommended Working Group on national assessment should start immediately - would form basis of insurance payouts. National assessment standards are essential. At the moment, the standards used to assess care needs vary from local authority to local authority and it is impossible to predict in advance whether councils will support applicants or not. This postcode lottery of care assessments causes huge distress and uncertainty. It is essential that a national standard is introduced - and it is this standard that would need to be used to determine when an insurance policy or savings plan would pay out for care needs. This work should proceed immediately, there is no excuse to delay.

More emphasis on prevention and integration of social care with NHS is also needed The Government says its work on care reform will focus on prevention and technology which can help keep people in their own homes, rather than needing to go into a care home. This is absolutely right - there are huge benefits in people being able to stay at home. It is a win-win - saving money to the NHS and improving older people's quality of life. More integration between health and social care services can also achieve huge savings, while benefiting patients too. Improving provision of care in people's homes can avoid emergency hospital admissions as well as facilitating faster discharge.

Dilnot says social care funding should only start once needs are 'substantial' - I disagree and this is a risk to those in 15% of councils currently receiving help with 'moderate' needs. The one part of Dilnot's recommendations that I fundamentally disagree with is his suggestion that state funding should only start when a person's needs are assessed as 'substantial'. This is unwise, because by helping people with moderate needs, it is more likely that reaching the 'substantial' or 'critical' stages would be delayed or avoided. There is also a huge risk now that any councils still offering funding for people with 'moderate' needs will be tempted to withdraw that funding, putting more vulnerable people at risk.

Spending on care will have to rise, because we are not spending enough now to provide decent care and numbers in need will increase significantly in future The fact that Dilnot's recommendations would require more state spending is not a reason to reject them. Social care spending will have to increase, given that standards are currently far too low anyway (and are being cut back) and also that the numbers needing care will rise by over 1.5million in coming years.

Paying for more spending could come from reassigning some NHS budget Where this money will come from is an important issue. Dilnot recommends a tax increase on older people specifically (perhaps using National Insurance after age 65 as a social insurance contribution to care). He also suggests reassigning some current spending - the most obvious route would be to take NHS money and spend it on care. This extra short-term spending on care would reduce health spending in future, and seems a very promising source of funding.

Conclusion: After so much hype, Andrew Dilnot's report seems to have been somewhat sidelined by the Government. He has been told that this is only a small part of a much bigger picture and that Government wants to get on with reforming the delivery of care, including more personalisation, choice, early intervention, prevention and technology and with better integration of health and social care services. The funding issue is being parked, Ministers will just be talking to stakeholders, but no White Paper will be coming out in the Spring, merely a 'progress report'. This is deeply disappointing for Dilnot, however the Government is certainly right to be concerned about the delivery of care, since standards of care in this country are lamentably low. What has not yet been addressed is the need for local authorities to have additional funding for care. The extra money so far supposedly designated to increase care has not been ring-fenced, so councils are still cutting back and using that extra money for other expenditure. This is not acceptable and must be urgently addressed. Dilnot rightly highlights the need for establishing national standardised assessment criteria and also for improved information and advice to help people and their families when they need care. Working Groups on these issues should not be delayed, even if details of a new funding system are left till later.


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