Sitting close to our specialist advisers, I’m in pole position to hear the range of calls they receive from older people and their relatives. A common call is from a relative with an elderly mum or dad in hospital, unable to return home, often after an acute event like a fall or a serious illness. ‘How do they find a good care home’, they want to know? Often the questions are about funding: ‘What is a top-up fee and why are they being asked to pay one’? And being a helpline, we often receive calls about problems with care. Why has my care package been refused or reduced, and what can I do about it? A recent call, from Bristol, was from a woman who had gone into hospital with pneumonia, received a reablement package in a care home on leaving but then found that the funding for her regular home care package had been withdrawn by her council.
One of the more regular things I hear our advisers saying is to the effect that: ‘It’s quite a complicated area but I’ll try to simplify it for you.’
Which got me thinking: why is social care so complicated? Why do we so obviously need experts who can make it understandable?
I think there are three reasons.
The first is because rules and regulations do often need to be complex, particularly if the intention is to accurately target people who most need a service. There is an inevitable trade-off between targeted support, which is most cost-effective but has to assessed against criteria, and universal benefits which are, well, universal but which also help those who may not be in need of them.
That said, as Andrew Dilnot has noted, the social care means test – with its sharp cut-off point for receiving any type of support - is one of the worst in the welfare state and that is some competition.
Care is also complex because people, families and agencies are at the interface between health and social care, a grey area where boundaries, responsibilities and actions can be very grey indeed. A grey area where – in a recent call to us from - a person’s departure from hospital to a care home can be delayed for months, at least in part, because no one can agree who should pay for the special chair that is needed in a care home.
The third reason is the most concerning, though, and begins to explain why the system remains complicated. It is because the system’s complexities have the effect of allowing – when necessary - the rationing of the resources available to councils. If people can’t understand their entitlements then they are less able to claim them. If complex rules and regulations make decisions difficult to understand or challenge then spending can be reduced. It’s a quality which means there may be little or no incentive to improve information on a council’s website because it may result in more demand.
Is that a cynical view? I don’t think so when there are now 400,000 fewer people receiving care and support than in 2009/10. That is equivalent to a city the size of Bristol.
Some of that reduction will have been because some universal services, or those for people with what used to be called ‘moderate’ needs, have been withdrawn. But others will be because eligibility criteria have been applied a little more rigorously or because promoting of services has been scaled back just a touch in order to ‘reduce demand’.
This type of rationing is wrong for a whole range of reasons but especially because it has the perverse effect of reducing demand from those who might most need it. Those who can put in the time and effort – though by no means all of them – are most likely to reap the reward. It inevitably discriminates against a frail elderly person, perhaps with dementia or who struggles to hear or see, who has no one to fight their corner for them.
It’s why we need not just a social care system which has more resources but also one which is simpler and clearer. That needs to start by having an honest debate about what our current system can really offer.
I came across this quote in a radical newspaper last week.
‘Old age care is never going to be cheap and with people living longer the bill is likely to rise. But the burden of funding old age care must at least be spread fairly, even if that means taxes having to rise’.
It was of course from that far left newspaper, the Daily Express. When the Express is calling for higher taxes perhaps we really have reached the tipping point for social care of which the CQC spoke recently.