Ministers have gone very quiet about the Dilnot Commission's proposals on long-term care funding. An ominous sign given the scale of the financial challenges ahead
The report of the Dilnot Commission on funding for long-term care, published last July, was broadly welcomed . A ‘realistic template’ said the Daily Telegraph. ‘Reasonable’ said Polly Toynbee in the Guardian. The government has promised a white paper on social care, incorporating responses to both Dilnot and the Law Commission’s recommendations on the reform of social care law, by Easter 2012.
However, subsequent discussion and debate on Dilnot has been remarkably quiet. Most worryingly, there is little indication from either the Department of Health or the Treasury that the Commission’s recommendations for a very small increase in public spending, to meet the very highest costs of long-term care experienced by a minority of older people, will feature in the white paper.
There are, however, wider questions to be asked. The Dilnot proposals only cover very high residential care costs. There is no debate on how to increase the overall funding for long-term care, in order to tackle the problems in a sector that is widely agreed to be seriously underfunded and beset by problems of poor quality. And there is an apparent reluctance to learn lessons from many other advanced welfare states that have, over the past two decades, developed collectively financed schemes to cover the costs of long-term care.
Many of these countries have also moved towards universal entitlements to public funding for long-term care; reduced extensive reliance on means - or assets-tested - schemes; and eradicated substantial local or regional variations in levels of funding and services. Underpinning these developments is the principle that the need for long-term care is a normal risk of life that society has a responsibility to provide protection against. New universal entitlements are also frequently linked to notions of citizenship (which may also increase popular commitment and willingness to pay for them).
Funding arrangements vary; many countries combine more than one of the following approaches:
- General (central and/or local) taxation that funds comprehensive, universally accessible services – typical of Scandinavian countries
- Part of the health insurance scheme (Belgium)
- A universal cash allowance funded from general taxation – Austria, Italy.
- A dedicated social insurance scheme - Germany, Japan, Netherlands, South Korea. Even the US is set to introduce a voluntary social insurance scheme in 2012 under the Community Living Assistance Services and Support (CLASS) Act.
The Dilnot Commission argued against social insurance on the grounds that it was not financially sustainable. Certainly Germany, Netherlands and Japan have all made recent changes in the face of rising costs – but without undermining the fundamental principles of universality and equitable treatment for people with similar levels of need. Indeed, Germany has actually introduced some modest extensions of its long-term care insurance benefits, reducing qualifying periods for benefits and increasing benefits for people with dementia.
Moreover, commitments to universality and equity are not incompatible with progressivity, in which the more affluent contribute more. Income or asset-linked taxes or social insurance contributions automatically mean that those with higher incomes contribute more. User charges can also be calibrated to reflect income levels – in France, user charges for the allocation personalisée d’autonomie rise so that the wealthiest older people receive only 10 per cent of the help they are assessed as needing – they are expected to fund the remainder themselves.
In many countries, collective funding meets only part of the total costs of care; older people and their families meet the difference or, if they cannot afford to, apply for means-tested social assistance to make up the difference.
One other feature of other countries’ approaches needs highlighting – the active role of central government in setting overall policies, funding regimes and often eligibility criteria as well. This is true even in highly decentralised federal states like Austria, Germany, Australia and Spain. A strong central government lead is essential in securing and safeguarding overall funding; integrating different assessment regimes; and ensuring equity across the country.
Debates about the overall approach to funding and delivering long-term care in England are urgently needed – and, sadly, were not prompted by the publication of Dilnot. England also seems strangely unwilling to learn from the experiences of other countries. Of course it is not realistic simply to import a different approach and impose it on our own institutions and cultures; but it is possible to introduce and adapt a radically different system, as Japan did in introducing its long-term care insurance scheme.
If Dilnot’s recommendations are not included in the spring 2012 white paper, we will have missed yet another opportunity for a very limited, incremental reform of one of the most unpopular elements of long-term care funding in England today. But even if the proposals are accepted in full, this still leaves a very large elephant in the room – the chronic under-funding of care, in both the residential and domiciliary sectors, which will only worsen as population ageing continues.
The Association of Directors of Adult Social Care has pinned its hopes on the next comprehensive spending review. Assuming older people can wait that long, we must start debating now what kind of system we want – and we have much to learn from the experiences of other countries.
Caroline Glendinning is chair of the Social Policy Association
