Taking the longer view, by Paul Gosling

24 Feb 05
If the forthcoming social care green paper avoids spelling out the cost of long-term care for older people, Sir Derek Wanless's review is likely to be less coy, argues Paul Gosling

25 February 2005

If the forthcoming social care green paper avoids spelling out the cost of long-term care for older people, Sir Derek Wanless's review is likely to be less coy, argues Paul Gosling

For Sir Derek Wanless, social care represents unfinished business. When he conducted his review of the NHS for the Treasury, he gave every appearance of regretting not being able to analyse the demand for, and cost of, care in the future.

'While the review considered it vital to extend its terms of reference to begin to consider social care, it has had neither the information nor the resources to be able to develop a "whole systems" model, nor indeed to build up projections for social care in the same level of detail as for health care,' Wanless wrote in his Treasury report.

But not only did Wanless recommend that such a detailed report should be produced, he gave a stark warning not to underestimate the costs likely to hit the state and service users in coming years. 'The projections show that population changes and the ageing of the population are a much greater cost pressure for social than for health care,' Wanless pointed out in his report.

Excluding children's and family services, and ignoring expectations of higher quality and more professionalised social care, Wanless still found that baseline personal social services expenditure will rise from £6.4bn in 2002/03 to £10bn-£11bn in 2022/23 'as a result of the impact of demography and health status changes', representing a real-terms increase of 2.3% to 2.8% per year. If Wanless gave off a sense of frustration that he had neither the powers nor the facilities to properly consider social care alongside health care in that earlier, government-commissioned, report, his pleas have now been answered.

Health think-tank the King's Fund, in line with calls from many other interested parties, including the Local Government Association, the NHS Confederation and the Association of Directors of Social Services, has commissioned Wanless to lead a review. This is due to report in spring next year on the 'long-term demand for and supply of social care for older people in England'.

The project will be led on the ground by Julien Forder, senior research fellow and deputy director of the London School of Economics' Personal Social Services Research Unit, which provided the data on social services for the Wanless Treasury review.

Although there has been speculation that social care minister Stephen Ladyman is irritated by the setting up of a review which might be expected to try to bounce the government into much higher expenditure on social care, the signs are that Ladyman is relaxed about the project. He says he 'welcomes' the review, and Forder told Public Finance that this sentiment was genuine. 'We have had nothing but positive comments from him about doing this,' says Forder.

In any case, Ladyman is preoccupied with one of the most difficult tasks in government – overseeing publication of the green paper on social care, now expected to be published in the second week of March, and likely to be central to Labour's election manifesto. It will probably be published at the same time as a green paper on youth policy and, in electoral terms, may become integrated into a wider debate on the treatment of elderly people, including pensions reform.

But the green paper was to have been published late last year. Ladyman has implied the delay is enabling the prime minister to be involved personally and to associate himself with its launch. But one person close to the process says the original version produced by Ladyman's small team of social care civil servants and advisers disappointed the minister by not being radical enough.

Policy disagreements have been another factor delaying publication. Some proposals expected in the green paper are not especially contentious. We are likely to see a move towards what is being termed the 'virtual care trust', involving even greater partnership and joint procurement between social services and primary care trusts.

PCTs will be pushed into further consolidation, becoming co-terminus with local authorities. Social service users will increasingly 'self-assess' their needs, with the expectation that this will lead to more tailored service provision and lower administrative costs.

And councils' directors of adult social care may take over statutory responsibility for local government's public health role, including environmental health – even though this responsibility currently sits with district councils in two-tier areas.

In itself, this measure is likely to be seen as driving forward some of the original Wanless proposals on strengthened public health. Responsibilities that might be taken on by adult social care directors include anti-smoking initiatives, sexual health, teenage pregnancies, diet and obesity, air quality and possibly even community safety and crime prevention.

But the green paper's sticking point has been on an issue which the minister himself suggested to PF last year had been resolved – the conflict between social care personalisation through direct payments and the agenda set by Sir Peter Gershon's efficiency review, which proposed large savings through centralised social care procurement.

That disagreement has been eased by the Department of Health's growing awareness that its enthusiasm for direct payments – where individuals buy their own social care, using state money – was not always matched by the users. Large numbers of elderly people do not wish to take responsibility for buying their care, especially when they are threatened with unwanted legal implications such as tax liabilities and employer's responsibilities. In pilot schemes the take-up rates have disappointed the DoH.

In a recent speech, Ladyman said that his commitment to the principle of direct payments remained, but he conceded the resistance from many service users. One option, he suggested, was for social workers to move towards becoming 'navigators' and 'brokers' for the buying of care on behalf of their clients. An alternative was to use voluntary organisations with experience of supporting independent living.

There is now speculation that by moving away from the generalised use of direct payments towards the purchase of care by intermediaries on behalf of service users, the Gershon and Ladyman agendas might be reconciled. An agreed framework of services and prices might be negotiated with service providers and perhaps published electronically for intermediaries to buy from.

The downside of this is that it potentially squashes the expected expansion of a sector of 'micro-providers' of social care – small organisations, or Mrs Jones down the road.

But the elimination, or at least professionalisation, of this new sector may be essential if other concerns are to be addressed: how to make sure that direct payments do not eliminate the informal care market, or make the state pay for support that has been provided free of charge (and estimated, by Carers UK, as worth £57bn a year). It also complies with proposals from Sir Michael Bichard – in his inquiry following the Soham murders – on the need to register carers who work with vulnerable adults.

It is the resourcing of this move towards improved care that presents a challenge which is more difficult to finesse. While the implications of the green paper are likely to be more expenditure on social care, this is something the government is unlikely to spell out in the run-up to the election. We can therefore expect the green paper to avoid costed specifics. The latest Wanless review could help to provide this. Much of its remit is to consider the cost of social care, a factor which at present is extremely difficult to quantify.

'Hopefully what Wanless will bring is a clearer understanding about the costs of social care now and in the future,' says Tim Hind, adviser to the Local Government Association. 'That will help us to answer how we can benchmark costs.'

William Laing, director of healthcare analysts Laing & Buisson, says that Wanless will also have to consider the specific pressures driving up costs in the sector. 'He has to take a view on the demographics, the extent to which there is generational change taking place, but also take a view on the inflationary pressures in terms of a more professionalised workforce in the future, what that means in money terms and take a view on informal care, which is a big wild card,' he says.

In Laing's view, Wanless will be forced to endorse elderly people meeting much of the costs of social care from their asset base of home ownership. 'The only real alternative to that would be the Scottish model [of free care for the elderly] and I can't see an appetite for that,' argues Laing.

Across the social services field, expectations are high about what will emerge from this latest Wanless review. Tony Hunter, president of the ADSS and director of supported living and community safety at Liverpool City Council, wants Wanless to produce a vision of social care in the future which goes beyond traditional models.

This would look at a broader consideration of improving the quality of life for older people and reducing the incidence of loneliness, especially important if trends continue and more elderly people live on their own.

'We would like to see support for the wider well-being approach that ADSS has been pushing for for some time,' says Hunter. 'As people get older they don't only expect to have their care needs met, but to go out to the cinema and go out for some chips.'

Julien Forden implicitly recognises the levels of expectations when he openly accepts the scale of the task now facing the team which he and Wanless are leading.

'What we would really like to do is with a reasonable degree of confidence say what an ideal social care system would look like in five, ten and 20 years' time,' explains Forden. 'That needs us to get a fairly good handle on what individual users expect and what society as a whole expects.

'That is quite a challenge. Partly that is because we are looking such a long way ahead and partly that is challenging because there is no obvious current message in the field providing a sense of direction. There is very little concrete research on this.'

But Forden says his team will avoid taking the easy options. While they could just take forward current costs without building in allowance for specific inflationary pressures, they are not going to do this. Nor will they shy away from specifying what mix of state, client and co-payment should be committed on care spending.

'It would duck our terms of reference just to say these will be the costs and not answer how it should be funded,' says Forden. 'We will take a view on the balance of contributions between the state and the individual.' He says that while these are 'political value judgements', the report will face up to them.

Given the forthright views that Derek Wanless himself is reportedly already making in private about the need to accept that more should be spent on social care, we can expect some blunt conclusions.


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