healthcare – Richard Brown

Interviewed by Laura Kuenssberg yesterday, Andy Burnham talked of a universal social care service, free at the point of use, on “NHS principles”. There’s been a lot of discussion about this pledge being kicked the other side of the general election, but less about whether these principles are actually the right starting point.

The starting point is presumably free domiciliary care at home and/or free care provision in a care or nursing home. In Scotland, which the PM referred to obliquely, free provision excludes non-care support such as help with shopping and housework at home, or accommodation and food costs in a care home. So, not quite the same as the NHS (you don’t pay for your food in hospital), but universal nonetheless.

(Incidentally, for all Burnham’s commitment to devolution, he seems to be less happy with the differences that may result from it. He said, “There is free personal care elsewhere in the UK. I don’t think it’s right that people in England don’t get the same.”)

Costs could be as high as £18.5 billion a year (around seven per cent of current health budgets) for a fully comprehensive care system by the mid-2030s, according to Health Foundation estimates, though Burnham said he expected the eventual numbers to be lower than that. For example, the Health Foundation estimates that a Scottish-style system would cost around £7.5 billion a year.

Care desperately needs sorting out, but I think the commitment to “NHS principles” risks locking us into an expensive and unsatisfactory system (which may not be sustainable for health costs either, though that’s another argument). At the margins, it could lead to crazy situations. One anecdote: a friend’s mother received continuing health care funding (available for the most seriously ill people) from the NHS for her live-in carers, plus visiting ‘domiciliary’ carers. Rather than continuing to deplete her savings at a rate of nearly £10,000 a month, friend’s mother started accumulating cash, as pension and investment income came into her bank account, without anything to spend them on (food was also supplied, through a tube, by the NHS).

It’s a mad story, but just an extreme example of what “NHS principles” could mean. Is the aim of social care reform really to take all the financial burden of paying for social care from individuals and placing it on general taxation, a huge extension of welfare provision? Or should it be about protecting people who need care from catastrophic costs (and taxpayers from catastrophic tax rises – more than 2p on the basic rate of income tax to generate £18.5 billion a year), while requiring those who can pay to make a contribution? Universalism is laudable, but it comes at a price when it protects the wealthy as much as the poor.

Since the Dilnot Commission 15 years ago, various permutations of ‘cap and floor’ have been explored to balance protection with private responsibility. Currently you receive care for free if you have assets valued at less than £14,250, and pay some costs if your assets are worth less than £23,250. These are pretty low sums (and include your house, if you have moved into a care home). Theresa May proposed raising the threshold, so that you would not have to pay care costs if you had less that £100,000 of assets. Boris Johnson’s equally unimplemented plan proposed instead a cap on costs; nobody would pay more than £86,000 over their lifetime on care.

One can quibble about the numbers (maybe both should be a bit higher?), but these approaches seem about right. Cap and floor are complementary: May’s floor protects poorer people; Johnson’s cap limits the impact for everyone. Almost anyone who has assets pays a bit, but nobody has to pay everything. Even the worst affected person (someone who starts needing care with precisely £186,000 in assets) retains more than half their wealth to pass on to the next generation. The approach still costs money, around £4 billion a year by the middle of the next decade, but is both cheaper and fairer (and the legislation is already in place).

But these, and other well-intentioned but complex proposals, have fallen foul of political sniping, wilful misrepresentation and flip-flopping changes in (Conservative) government. So you can see why Andy Burnham wants to opt for a model that people understand: “I am talking about a system that works on NHS principles because that is the only way you can make it work.”

That may make it work in presentational terms, for the purposes of a conference-eve interview, but I do hope the Prime Minister will in due course present a policy that protects people, but in way that is proportionate to their needs and to their ability to pay their own way.

Let’s start with the good news, such as it is. The immigration white paper published on Monday re-affirms the government’s commitment to a “fair pay agreement” to improve the terrible pay and conditions faced by care workers. This cannot come soon enough, but whether it will be sufficient, alongside withdrawal of the social care visa, to avoid a social care staffing crisis is another question.

London is at the sharp end, as the Skills for Care dashboard shows. The capital has the highest care worker vacancy rates in England: 11 per cent compared to an average of eight per cent across the country, with vacancies highest in the “independent” sector (that is, not directly employed by the NHS or local authorities), which accounts for four fifths of the city’s 250,000 adult social care workers.

These include workers in care homes, nursing homes and ‘domiciliary’ carers who visit mainly elderly clients (precise numbers are hard to come by, but around 60-70 per cent of adult social care clients are over 65) in their own homes to help them with food, getting dressed, washing and personal care.

London’s care workforce is older than elsewhere and includes more foreign nationals: 54 per cent are British, compared to 73 per cent across all England and 80 per cent-plus in the north. Workers directly employed by London local authorities are paid an average of £15.52 per hour, but these are only a small minority.

Those in the independent sector receive an average of £11.54 – little more than their counterparts outside London and substantially less than the London Living Wage of £13.85. Lastly, and these factors may all be connected, London’s care workers are far more likely to be employed through an agency and on zero hours contracts.

So, if a staffing crisis hits, London will be in the front line. A fair pay agreement may help over time, but if there are vacancies across the country during a transition period, London’s care workers may vote with their feet, seeking better pay and conditions beyond the M25.

But – and I don’t think this point is made enough – it’s not just about pay. The best care workers I have met are those who feel a genuine sense of vocation. As well as the patience, gentleness, and physical and emotional strength to deal with frail bodies and failing minds, these carers genuinely love the work they do, looking past the difficulties to take pride in looking after other humans. We shouldn’t exploit their calling with poor wages. But I’m not sure a pay boost, together with some general gesticulating towards economically inactive people, is enough either.

Setting that to one side, how would a 20 per cent pay rise (based on raising the average to London Living wage) for London’s care workers be funded? Though local authorities only employ a minority of care workers, they generally pay care costs for anyone with assets of less than £14,250 and a proportion of costs for those with up to £23,250. (Hammersmith & Fulham Council is one of the few local authorities not to apply a means test for domiciliary care and day care).

In London around 70 per cent of people in care homes and 85 per cent of those receiving care at home are local authority-funded – some of the highest proportions in the country, reflecting the relative poverty of London’s older people. Given growing demand from an aging population, national insurance rises and adult social care overspends mounting up every year, boroughs would struggle to pay an extra 20 per cent on care home and care agency fees. And it doesn’t look as if the government is inclined to pay them more.

For those paying fees themselves, an increase in costs might mean quicker draining of capital reserves (and recourse to local authority support), or attempts to cut back on spending. But cutting back on care provision could be a false economy. Battling on, as many older people are inclined to do, can raise the risk of accidents at home and send more older people into hospital. Finding enough carers to provide short-term “re-ablement” support for them when they leave hospital is already a challenge. Shortages of care staff will likely mean longer hospital stays for “medically fit” older people – adding to pressure on beds, and often resulting in worse health when they do leave.

Alternatively, family members could be asked to do more, as Conservative ministers have occasionally suggested. But is it right or economically sensible to ask people (generally women) to leave careers at a time of peak earnings to become full-time carers? Families need to be involved in care but abandoning other plans to become a live-in carer for elderly parents, as many women of my mother’s generation did, is not going to work for everyone.

The whole thing is a mess, and is going to become messier as the population ages. Yes, we need to improve pay, conditions and esteem. And yes, we probably should enable some continued immigration for the care sector. But the whole system needs a rethink. It’s not new to say this. There have been plenty of reviews (the Casey Review announced earlier this month is the latest in a long line), and more or less sensible ideas for caps on care costs, for compulsory insurance policies and for levies on estates. But all have been shot down or proved electorally toxic.

The problem is, as the Financial Times’s Stephen Bush observed this week, “at any given time, most people are not experiencing the care crisis”. And when we stop experiencing it, we don’t want to think about it any more. I don’t really want to think and write about it. My parents no longer receive care and I hope it’s a few years before I need to. But we need to find a better way. What we have now simply isn’t good enough, and I fear it’s about to get worse.