It is the duty of the state to guarantee a basic level of care to everyone
22 June 2007 | Robin Wendt, individual contributorAlmost 10 years ago, I was privileged to be asked by the then Health Secretary, Frank Dobson, to be a member of the Royal Commission on Long Term Care Funding; this Commission was set up by the incoming Labour government to fulfil an election pledge.
The 12 members of the Commission were from a variety of public, private and voluntary backgrounds. We collected a mass of oral and written evidence, held public meetings throughout the UK, and studied arrangements in other countries. In March 1999 we recommended, by a large majority, that the cost of ‘intimate’ personal care required as a result of illness or disability, such as washing, feeding and toileting, should in principle be met by the state from general taxation. Our reasoning was founded in simple equity and morality. We judged that the cost was affordable, at least by a government determined to tackle this issue.
Our recommendation did not – as some of our detractors have claimed – amount to ‘free personal care’. Rather it meant that the government should pay a fixed but generous amount of all care home bills to reflect nursing and personal care costs, with people meeting ‘board and lodging’ costs from their own resources on a means-tested basis. In the jargon, the Commission advocated ‘co-payment’ in which costs are shared between state and individuals, a system that works effectively in Scotland.
Ten years on, I have no doubt that this is the right medium-term approach. People don’t get ill or disabled through their own fault; if the state can fund care for people with cancer then it should also fund it for old folk who have falls or develop Alzheimer’s. If the Commission made a mistake, it was not to insist that personal care in these circumstances should really be part of the NHS.
It’s very interesting that the Wanless study for the King’s Fund, which, like the Royal Commission, had no preconceptions, came to a similar conclusion – that it is the state’s duty to guarantee a basic level of care to everyone irrespective of means. That’s what a decent welfare state should be about.
Over the past year I have been handling the financial affairs of a very old relative, now in a poor and confused state in a nursing home following a fall. This experience has brought home to me the justice of the Royal Commission and Wanless proposals. Although above the means-testing line, she is by no means wealthy. But month by month her hard-earned income and savings get drawn down to pay for care that she has not volunteered for.
So I really welcome this Caring Choices coalition and wish it well. The campaign to put England, Wales and Northern Ireland on a similar ‘co-payment’ basis to Scotland must continue to the point where ministers can no longer patronise or ignore it. And we must ensure the issues get to Cabinet level and don’t stay stuck with transient junior ministers.
June 22nd, 2007 at 4:50 pm
The measured and sensible views expressed in this email so exactly mirror my own I could have written it myself. I suspect that those lucky enough not to have experienced this illness do not realise that incontinence and the inability to wipe one’s bottom are part and parcel of dementia, as much as the inability to recognise one’s nearest and dearest. Like the writer’s relative my mother was not wealthy, but had savings in excess of the means test limit. And as her savings creaked and groaned to meet nursing home bills that rose by £75 a week, Blair and Brown bragged that inflation and interest rates were at the lowest levels in living memory. What angers me more than anything is that tax was deducted from her modest savings income (she had no pension) and from the reduced residue I had to pay the home. These people are not the private equity/hedge fund super rich whose presence in London is eagerly welcomed by politicians, but elderly people of very modest means.
July 25th, 2007 at 10:20 pm
i would agree that the present system leads to inequality of funding and choice in care. I would like to note though that the article focuses on ‘care home’ funding. One of the problems can be that for social services and health care funded clients more money is spent on the care home client than the one whose family try to maintain them at home. in this area a social services residential cost is about
£320 per week but if it costs more than about £250 a week at home it is said to be too much. Where is the sense in that?
August 9th, 2007 at 12:07 am
I am a nurse working in palliaitve care, with people who have incurable illness. We frequently have to discharge patients, when they do not die quickly enough, to nursing homes where their care is means-tested and no longer free – as it is in our hospice.
Try as I might, I cannot see how to distinguish the needs of those who have a short prgnosis from those who have a long or indeterminate one, and why the former should have free care but the latter cannot. Why should someone suffering from slow-developing Alzheimers Disease not deserve the same standard of free care as someone with a fast -growing cancer?
Those who will die quickly can have free care because it is cheap. Those with long-term conditions are too expensive because they live too long. This is the real reason for the anomaly.
I have 3 proposals:
1. Base all care (personal and nursing) for those who are not going to get better from their illness or old age frailty, on the free palliative care model.
2. Stop trying to distinguish personal and health care. Millions of pounds are being wasted trying to do this and they cannot be satisfactorily separated. Even if they could, what is the ethical case for the state paying for one and not the other?
3. Pay these costs out of taxation. We pay for the NHS this way. It would be an extension of it and seems the most egalitarian way to make the ‘co-payments’ described above. Taxation is itself a system of joint state and individual responsibility.
I know politicans say that this would be politically unacceptable but if the case was made clearly, honestly, persuasively and persistently over a period of months it could be done. Governments are very good at ‘marketing’ ideas and this would be a brave and respected one. I have never met anyone who doesn’t want to be sure they will be looked after well in old age. We are a rich country and can afford the small redistribution of resources to achieve this.
October 5th, 2007 at 9:06 am
My father has just been admitted to hospital for the second time this year due to falling over.
I have been told there is no way he should be left alone & needs constant nursing.
He is fighting us in wanting to stay independent with no help but as the last time he fell he was discovered in the morning in an hypothermic state we have a great problem in deciding what to do with him.
Do we just abandon him & leave the state to sort out the problem or do we try to plan without his agreement.
October 8th, 2007 at 10:42 pm
Thank you, Robin, for starting this thread, and thank you for the work you have done with the Royal Commission.
It amazes me that, in browsing many web-sites concerned with the subject, I have found not one reference to the Royal Commssion Report of 1999, or its Statement which followed in 2003. Consequently, I have copied and pasted below a message which I originally posted in another thread on this site:-
What I want to know is – why did Gordon Brown as Chancellor, and Tony Blair as Prime Minister, ignore the findings and recommendations of the Royal Commission Report, ‘With Respect to Old Age’, produced in 1999? (The Sutherland Report)?
Following extensive consultation, research and costing, this comprehensive Report looked at various options for funding and finally recommended:
‘The costs of long-term care should be split between living costs, housing costs and personal care. Personal care should be available, after assessment, according to need and paid for from general taxation: the rest should be subject to co-payment according to means.’
The recommendations were implemented in Scotland where care is, in effect, subsidised by tax payers in the south of England.
After the Government’s failure to act, the Royal Commission issued a further Statement in 2003 which included:
‘There are no overwhelming resource implications to the implementation of the Royal Commission’s recommendation. If Government believes that long-term care funding is an important issue – and presumably it does, otherwise the Royal Commission would not have been set up – it can find the necessary resources both now and in the future. More important, the limited changes to the care funding system in England, Wales and Northern Ireland have not addressed the deep-seated issue of inequity, hardship and the need for a principled approach across the United Kingdom. The system in these countries is unstable. If not dealt with in the near future, it will implode.’
Eight years on and we’re still debating it!!!
Both the full Report and the Statement are available on-line. Easiest to ’google’ for them.
January 9th, 2008 at 10:20 pm
It never ceases to amaze me that whilst the government says that it wants to see more people be treated at home in the community it is withdrawing much of the funding to support this (e.g. incontinence products provision), surely it is cheaper to support those individuals at home where possible rather than in a care home.
February 6th, 2008 at 6:56 pm
When the NHS was setup it was setup to provide free care at the point of use, not free care unless you are old, in need of long term care and through you own hard work and prudence have the means to pay for it yourself. The funding for long term care often comes at a high price with many being forced to sell what has been a family home just to fund the care bill. This causes additional distress to often quite venerable people.
The big political debate last October was inheritance tax, with both parties using this to gain political advantage, yet the provision of long term care and the funding of this long term care can provide a bigger threat than inheritance tax ever did to the wealth of a family and it’s emotional well being.
As with inheritance tax the well educated and prepared can write wills to protect part of the estate from the ravages of care costs, this also in many cases protects the family home from forced sale and relieves an additional worry for someone who is already stressed by needing long term care.
Although funding of long term care costs is likely to be a much more expensive nut to crack than inheritance tax, when can we expect to see politicians take a really interest in solving this issue and abating the vast harm it’s effects have on many families lives?
In meantime, use the devices at your disposal, wills & trusts maybe if enough people protect assets in this way as they did with Nil Rate Band Discretionary Trust Wills, then we might see the rules changed to make a fairer system overall.