Shaping the Future of Social Care Together

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Shaping the Future of Care Together

TUC Response

Summary

Introduction

Inequality, poverty and social care

Problems with the current system

Principles for social care

What people expect from social care

An evaluation of the funding options

General comments

The tax-funded option

The partnership option

The insurance option

The comprehensive option

Securing payment after death

National or local?

A part national, part local system

A national system

Workforce issues

Conclusion

Issue date

27 Sep 2010

The TUC response to the Green Paper on future funding for adult long-term care and support services tackles the major questions presented as part of the 'Big Care Debate.' The response squarely registers the TUC's disappointment that a fully tax-funded care system was ruled out in the Green Paper and after considering the other options put forward, the TUC still considers NHS style funding to be the simplest, most equitable and progressive. We know that many individuals and organisations taking part in the Big Care Debate share this view and hope that an NHS system of funding will receive more attention and be accepted for the future of social care. Cost and quality are the two key crucial issues facing social care yet underfunding of care means that many staff are poorly paid and insufficiently trained. A high quality social care system depends on well-paid, well motivated and trained staff, yet there is next to no consideration in the Green Paper about the contribution they make or how they can be better supported. Extra investment is desperately needed in the social care system and particularly its workforce.

In reaching the decision about funding, we place the social care system within the wider social context and look at the high levels of inequality and poverty in the UK. This provides the backdrop for the national debate, as growing numbers of people in need are turning to social care services. Our social care system is currently in crisis as too many people fail to access the support they need, while demographic changes are putting additional pressure on a system already at breaking point.

There are major problems with the current system that need to be addressed as a matter of priority. These include the lack of a consistent national framework, the inconsistent and unfair effects of means- and needs-testing, the confusion and uncertainty that face people trying to navigate the system and lack of choice people face within the system. These defects have led us to give strong support to the concept of a National Care Service with a single national standard for assessments and eligibility. We believe that the national assessment will go a long way to addressing these problems.

The National Care Service should be underpinned by three principles: respect, equality and independence. Based on these principles, we call for the new National Care Service to ensure that social care services should aim, wherever possible, to help people to continue for as long as possible to lead independent lives in their own homes and to make decisions about their lives for themselves. Even when it is no longer possible for someone to continue to live in their own home or to make some decisions for themselves, social care should still aim to maximise their independence, dignity and respect. We believe that an England-wide service that embodies these principles should emphasise national standards, rather than local autonomy.

The National Care Service will not be able to achieve the key goals of respect, equality and independence without a significant step change in funding. Social care is chronically underfunded, meaning that too many people miss out on the care and support they need. While the TUC's welcomes the proposed shift from a model that provides support only to those in greatest need to one where everyone receives some support, the 'Big Care Debate' has unfortunately been a missed opportunity for a national discussion about how we fund our essential services. Until we have a proper debate about the share of GDP the country wishes to see spent on social care, real reform will not be possible.

Real reform of the social care system requires extra resources, yet the TUC believes that the only system capable of providing for increased funding is a fully tax-funded system. It is therefore disappointing that the Green Paper, in putting forward proposals for the future of social care, removes this option. The TUC believes this is a mistake and that social care should be funded in the same way as the NHS. This is the most equitable option and presents the only opportunity to increase funding and improve social care provision.

The Green Paper proposals to include Disability Living Allowance and Attendance Allowance paid to over-65s in the funding for social care risks a transfer of funds from those with less severe impairments to those with more severe conditions. While the extra money for the most disadvantaged is welcome, the reduction in income of around a third of a million other disabled people will cut the incomes of a group which includes many people who will be pushed into poverty as a result.

The Green Paper considers the balance between national government and local government control and whether the National Care Service should have a nationally or locally determined funding system. The TUC strongly supports national rules in order to fully support the national system of assessment and eligibility. This is at the heart of the new National Care Service and without it, most of the advantages of the concept would be lost.

Finally, but most perhaps most worryingly, the Green Paper gives very little space to workforce issues, despite the current problems of low pay, high turnover and a lack of training culture in the social care sector. A high quality social care system is only achievable through a well-paid, well-motivated and properly trained workforce. We are worried by the pervasive assumption in the Green Paper that, once the policy and structural issues have been decided, the delivery of the new National Care Service can simply be assumed as a matter of course. Good industrial relations and a committed staff have to be worked for and planned for and that planning should start now.

In 2008, the Government inaugurated a 'national debate' on the long-term future of social care in England. The TUC was very pleased that the Government has opened the debate about the future of social care. Unions began life as part of the response of the working class to the insecurities of a modern industrial economy, and unions had important welfare functions as well as an industrial role well into the twentieth century. Several unions continue to offer their members important welfare services or include a charitable arm.

Because of this background, the TUC has long had a vital interest in the development of the welfare state - William Beveridge called us the 'godfather of the Beveridge report'. Social care is a neglected part of the welfare state and trade unions have been increasingly convinced that a fundamental and wide-ranging review is needed. The TUC and our affiliated unions made strenuous efforts to participate fully in the 2008 debate, concluding with the production of a substantial TUC response.

In July 2009, the Government published Shaping the Future of Care Together, a Green Paper which proposed the creation of a National Care Service and asked for comments on a number of options for funding it. The trade union movement has again been keen to participate in the debate about these proposals. Since July the National Care Service and the union response have been debated by the TUC's Pensioners', Women's, Disability and Race Relations Committees, at a special meeting for union research officers, at a seminar open to all trades unionists (addressed by Phil Hope MP, the Minister for Social Care) and by the TUC Executive Committee (twice).

Unions representing workers in all social care services have taken part in this discussion. Our comments also represent the views of workers in all walks of life - we speak for nearly 6.5 million workers in our 58 affiliated unions; one worker in every four belongs to a TUC affiliated union. The whole trade union movement has an interest in the future of the welfare state because secure and prosperous employment and profitable enterprises rely on the strength and depth of our social infrastructure.

Social care policy must be understood in context and the main contextual factor is the degree of inequality and poverty in this country. For both pensioners and adults of working age, the demand for social care services will be positively linked to the level of inequality and an increase in the numbers in poverty will lead to an increase in the number of individuals who need those services.

In a rich society, the degree of inequality is almost certainly one of the factors that determine the health of the people. The Whitehall Studies of British civil servants have revealed the unequal incidence of illness and disease: civil servants in the lowest grades are much more likely to die prematurely than those in the highest grades.

The Equality Trust has pointed out that, among richer countries, differences in health outcomes are very closely related to differences in income inequality: the more unequal a country is, the worse its outcomes. A review of 155 research papers, with 169 analyses, found that 88 were 'wholly supportive' of the hypothesis 'that greater income differences are associated with lower standards of population health,' 44 were 'partially supportive' and 37 'unsupportive'. A study using WHO and UNDP data covering 94.4 per cent of the world population found that 'social inequality seems to have a universal negative impact on health.' An unequal society has worse health outcomes for everyone in that society: 'mortality is higher for a given level of overall income in more unequal nations.'

This association also applies to mental health; as the World Health Organisation put it in a report drawing heavily on British evidence, poor mental health is 'both a cause and a consequence of the experience of social, economic and environmental inequalities. Mental health problems are more common in areas of deprivation and poor mental health is consistently associated with unemployment, less education, low income or material standard of living, in addition to poor physical health and adverse life events.'

A great deal of time has been spent discussing the growth of social care costs. We should be prepared for this in light of the massive growth of inequality in the 1980s, which has not been reversed since:

Chart showing inequality rising

Inequality in this country is not only high historically, it is also high by European standards. The table below shows the ratio of total income received by the 20 % of the population with the highest income to that received by the 20 % of the population with the lowest income. Of those countries with which we typically compare ourselves, only Italy matches this country's degree of inequality:

Chart showing fairly high inequality in the UK by European standards

The degree of inequality in this country helps explain the high level of demand for social care services. The individuals who are likely to need help from social care services are those who are poor. As the Social Care Institute for Excellence has reported, 'it is accepted that families living in poverty are over represented as users of some children's and families' services, including those of an involuntary rather than voluntary nature.'

Vulnerable working age adults are now more at risk of poverty than they were in the mid-1990s. Child poverty has been the central concern of the Government's anti-poverty policies, and there has been success on this front, with more than half a million children being taken out of poverty. The Government's strategy has made paid work the key to escaping from poverty and again there have been real achievements, hundreds of thousands of individuals from disadvantaged groups (such as lone parents and disabled people) have moved into paid employment.

But, for those missed out by the objective and the strategy - childless people who fail to get paid jobs - there has been no progress, with increasing numbers facing poverty.

In 2007/8 there were 23.1 million working age adults without children;
14 per cent of them were poor.
Working age adults without children are still less likely to be poor (14 per cent) than those who do have children (18 per cent);
But the proportion has been rising for those without children (from 12 per cent in 1997/8),
And falling for those with children (from 20 per cent).

Overall, there has been a two percentage point increase in the risk of poverty for working age adults without children:

Working age adults without children: proportion in poverty, before housing costs (%)

This is significant enough; as the table shows, the increase in the risk of poverty has been even steeper for those adults without children who are 'work-poor'. These three groups altogether account for almost 7 million people:

Three work-poor groups in 2007/8

Group	Number (millions)	Number in poverty
No full-time, one or more in part-time work	2.2	500,000
Workless, one or more unemployed	0.9	500,000
Workless, other inactive	3. 7	1,400,000

An even larger group whose poverty is likely to lead to greater demand for social care services is pensioners and here the Government can point to significant success. The number of pensioners living in poverty has fallen by 200,000, though this still leaves a large number in poverty.

Pensioner poverty[11]

Period	97/98-99/00	99/00-01/02	01/02-03/04	03/04-05/06	05/06-07/08
Number of poor pensioners (millions)	2.6	2.6	2.5	2.3	2.4

These figures use the Government's definition of poverty, which is calculated before housing costs and benefits are taken into account. If the definition favoured by anti-poverty groups were used - calculated after housing costs - the reduction in the number of pensioners in poverty would be more impressive: from 2.8 million to 2.0 million.

However the figure is calculated, however, there are still at least 2 million pensioners in poverty, and this is likely to lead to a continuing high demand for social care services.

The Green Paper effectively analyses and describes the problems afflicting current social care provision (it would be misleading to describe it as a 'system' as it has never been planned.) We agree with the characterisation of the current system as suffering from serious weaknesses, including:

The absence of a consistent national framework. Local authorities interpret the guidelines in different ways, so that -

The level of need necessary to qualify for support variesa great deal, and

The contribution individuals have to make also varies.

People feel it is very unfair when they can see that, if they lived in a local authority just a short distance away, they would be much better off. Disabled people who live in a local authority with a good policy are constrained about where they live in a way which does not affect their non-disabled counterparts - higher charges (which could amount to several thousand pounds a year) or the non-availability of services can mean that moving to a local authority where policy is not good simply is not practicable. For people in employment there are severe constraints on which jobs they can take and whether they can apply for (or accept) promotion or re-deployment.

Means- and needs-testing. The TUC objects to means-testing in principle. The confusion of provision can mean that means-testing in social care is particularly unfair: some people receive no care, some have to run down their savings and resources until they have very little left, some receive no care until their needs are extreme.

Confusion. The Green Paper correctly points to the effects of a lack of rules about people's entitlement -

At stressful times people have a fight on their hands (sometimes with several bureaucracies at the same time) to establish their entitlement to services.

Information, advice and guidance on entitlements do not exist or have been developed by charities and campaign groups through bitter experiences.

Transitions are particularly difficult. The problems of moving from services for children to services for adults are well known. Moving from care in one's own home to residential care can also be a stressful time as it can be difficult to discover what one is entitled to. People who need support from both the NHS and the local authority, or who have to move between the two also face serious obstacles. Our members who have had to arrange care have impressed on us the difficulties - financial, as well as emotional - of these periods.

The Green Paper correctly points out that, even if one has the resources to make one's own provision, it is impossible to plan for one's own future of the future of a person one is caring for.

Hobson's choice. Care services do not always cater for individual needs or for needs that differ from the mainstream. Often this is the result of severe resource constraints.

Underfunding. Social care is seriously underfunded now and, the Government estimates that if funding does not change, then there will be £6 billion gap in funding over the next 20 years. However, the gap will be a great deal more than this if it is to improve in terms of both quality and quantity. There is a both a high level of unmet need - most due to trends in reducing the amount of support given to people with low or moderate needs in favour of high needs - and problems with the quality of care provided at the moment. This is most seriously manifested in the treatment of the social care workforce. Although staff costs make up a large proportion of social care costs, they have been driven further and further down over recent years. The sector is characterised by an overreliance on National Minimum Wage levels, a poor commitment to training and development and high staff turnover. It is vital that increased funding is made available to improve both quality and quantity and to plan for future care needs.

Lack of integration. The Green Paper states that for the National Care Service to work, we will need services that are joined up, give you choice around what kind of care and support you get, and are high quality. We believe that the drive to privatisation and the use of direct payments represents the major barrier to joined up services. The fragmentation of social care, driven by the pressure to cut costs can only place obstacles in the way of quality, integrated services. We believe that quality, integrated services are best provided in the public sector where they are well regulated and best meet the needs of the local community.

In our response to the 2008 national debate, the TUC noted that, when local authorities assess service users' needs, they put them in one of four categories: low, moderate, substantial and critical. In a survey of local authority care charging and eligibility criteria, Counsel and Care found that, in more than two-thirds of local authorities, only those people assessed as having 'critical' or 'substantial' needs were judged to be eligible for services. Three councils only provided services for those whose needs are 'critical.' While local authorities are not required to charge for services for older people, Counsel and Care reported that 'the vast majority' did. Only two of the local authorities they surveyed did not charge for home care services, with others charging up to £18 an hour.

This is a problem that is getting worse. A year ago, the Commission for Social Care Inspection reported that 'in 2006-07, the proportion of councils who set their eligibility at 'substantial' or 'critical' level of risk increased from 53% to 62%. In 2007-08, 72% of councils were operating at 'substantial' or 'critical' level. (70% of councils set the threshold at 'substantial' and 2% at 'critical'.)' In 2007 the High Court ruled that local authorities could lawfully restrict eligibility to people with needs assessed as 'critical'.

At a time when demographic change should be producing accelerating demand for social care services, CSCI report the remarkable facts that:

In 1997 479,000 households received supported home care

By 2006 this had fallen to 358,000

Between 2003 and 2006 the proportion of older people receiving care services in the community arranged by their local authority actually fell.

Counsel and Care described the situation in bleak terms: 'only those older people with the highest dependency needs, without any available family support and on low incomes, will get council services.'

The TUC believes that this picture illustrates why we need a national service and, in particular, national standards of assessment and eligibility. The TUC strongly supports the creation of a National Care Service.

Last year the TUC considered the principles that should underlie reform of social care. We were very influenced by the Disability Agenda, published in 2007 by the Disability Rights Commission (which has since been replaced by the Equality and Human Rights Commission). The principles we have adopted in our contribution to the national debate are very similar to the Government's 'vision' of independence, choice and control:

Respect.By this we mean recognition of the dignity of every person. Evidence from fields as diverse as anthropology, sociology and behavioural economics has revealed how damaging it is to be denied equal respect; it is for this reason that article 1 of the UN Declaration of Human Rights begins by declaring that 'all human beings are born free and equal in dignity and rights.' On those occasions when social care fails it is the absence of respect that makes the failure shocking; it is therefore a fundamental value for public services.

Equality.When social care services are a marked success it is often because they expand the boundaries of equality, making it integration possible for groups who had previously been excluded from the normal life of society. The principle of equality follows on from the principle of respect; no one should be a second-class citizen, with inferior rights to services as this would be to deny them respect. This does not, however, mean that social care services should aim at uniformity - sometimes, to treat people equally, it is necessary to treat them differently.

Independence. As the TUC noted last year, a society cannot claim to respect the dignity of users of social care services if it does not allow them the choice and control that are the mark of an adult's life in our society. Choice and control are enhanced by guaranteeing service users rights to involvement in decision-making, participation in setting goals and a voice in evaluating different options.

These principles lead the TUC to some conclusions about the nature of social care services.

Instead of regarding social care services as special help for groups that are regarded as deficient in some respect, they might better be regarded as services that any of us may need at different times to help us continue in the human task of living a good life. Social care services should be regarded as (amongst other things) part of the effort to make our society truly accessible to all. In this light, it is a mistake to draw distinctions between people with physical impairments, people with mental health problems and people with learning difficulties. Of course, all these different groups may need different services, based on different approaches, but all should aim at promoting respect, equality and independence. In the words of the Centre for Citizen Participation, we believe in 'a vision of social care that is participatory, rights-based and holistic in approach.'[17]

Furthermore, we are very reluctant to accept that there should be different systems for young and old people. There is very little detail in the Green Paper about funding or support for people of working age, concentrating instead on older people. Younger disabled people, usually lack the resources to pay for care because of limited opportunities to work or save, but are often excluded from state support by high eligibility criteria or charges. Any reforms to funding or delivery structures should address resource needs across the whole of the social care system.

A third conclusion from our principles is that living in one's own home is normally a mark of dignity, equality and independence. The Green Paper's focus on enabling people to stay in their homes rather than residential care is particularly welcome and one that must be developed as a general concept. We also welcome the Government's announcement that people with "the highest needs" are to receive home care regardless of personal wealth. But our principles equally mean that the effort to promote dignity, equality and independence should continue once someone has entered residential care - social care and support should be focused on enabling people to live to their potential.

Similarly, being able to manage one's own affairs is a mark of citizenship. Prevention and measures to put off the point when one is no longer able to do so should be important health and social care services. But equally, we should regard advocacy services, not as recognising that a battle has been lost, but as a way to maintain independence. The 2001 Health and Social Care Act requires the Secretary of State for Health to arrange independent advocacy services to help with complaints about healthcare services. The case for a much broader service, giving every citizen a right to independent advocacy whenever his or her ability to make a decision is questioned is very persuasive.[18]

We accept that some people lack the capacity to make important decisions, but these restrictions should never be too sweeping. As people with learning disabilities have argued, some adults may not be able to make decisions about their money (for instance), but that does not necessarily mean that it is right to tell them what clothes to wear, what food to eat, when to go to bed or what relationships are acceptable. The National Care Service should be organised on the assumption that, even where some limitations on independence are unavoidable, they should always be kept to the minimum necessary.

A final immediate conclusion from these principles is that the 'postcode lottery' is unacceptable. The TUC believes that UK citizens should have a right to social care services and that these services should therefore be organised to minimise the differences in entitlement from part of the country to another. We consider this issue further below.

People's views of the current system and their relative support for different reform options are easier to obtain today, as a result of last year's national debate on care and support. The responses to this debate fully confirms one of the main points in the Green Paper - the confusion caused by the existing hotchpotch, and just how difficult it is to understand. Members of the public only understood those elements of the system they had come into contact with and often confused it with the NHS. Even those with some experience of care services were confused about how they were funded and managed.

In last year's debate the Government outlined a vision of a system which promotes independence, choice and control and this seems to have been broadly supported, both by the general public and 'stakeholder' organisations with greater knowledge of the system (though the latter expressed more concerns about how to make this vision a reality.)

The people who took part in the debate were particularly worried about the 'postcode lottery':

62 per cent agreed with 'national control of budgets and national consistency - people should know they will get the same support whenever they live';

17 per cent agreed with 'local control of budgets and local flexibility - local people should have a say.'

By a margin of two-to-one the participants disagreed with a 'nature red in tooth and claw' approach; when presented with the statement 'people should pay for their own care and support needs', 56 per cent disagreed and just 28 per cent agreed. 88 per cent of people agreed with the statement 'it is better to pay for care before you need it, rather than when you need it'; just 8 per cent disagreed.

The Green Paper says that, at last year's consultation events, the most heated debates took place on the funding arrangements. The summary of the consultations introduces a political note to the summary of these discussions:

'Free at point of need was seen as desirable and the most appropriate model, but many felt that it is unachievable, and a form of co-payment was perceived to be the best compromise solution.

'Taxation was seen as the most equitable solution but there was also recognition that this is unlikely to be politically acceptable.'

Most participants seem to have believed that, politics aside, 'funding through taxation is the most equitable solution and that a collective approach to funding would help pool risk and ensure that individuals were not left unable to pay for their care and support.' On the other hand, when asked whether the Government should target support on people with the lowest incomes and assets or provide everyone with the same level of support, participants preferred the former by 44 per cent to 33 per cent.

When participants were asked to consider who should bear the burden of the likely increase in the cost of social care their strong preference was for the whole of society taking up the burden:

Who should pay more in the future?

Everyone in society	82%
Individuals who need care and support service	8%
Families of individuals who need care and support services	8%
No answer	2%

As is so often the case in public discussions about social justice, a great deal depends on the way in which the question is put. The terms of the national debate - which emphasised the growing costs of social care - are very likely to have led participants to assume that what they wanted was unrealistic. An important framing element is the leadership given by politicians - by the options they include and exclude they indicate the size of the realm of the possible.

On 29 September the Prime Minister addressed the Labour Party conference; he announced that the next Labour Party manifesto would include the creation of a National Care Service. The passages that received the most enthusiastic response were those that suggested that the new Service would be organised on an egalitarian and universalistic basis:

'And so for those with the highest needs we will now offer in their own homes free personal care.

'It's a change that makes saving worthwhile, makes every family in this country more secure and is a much needed reassurance for the elderly and their children.

'This is the change we choose; change that will benefit not just the few who can afford to pay, but the mainstream majority.'

The name that has aroused such enthusiasm - National Care Service - suggests that the new Service will be organised in the same way as the National Health Service.

The TUC believes that the response to the Prime Minister's speech and the results of the national debate in 2008 indicate that, given the appropriate lead, there would be strong public support for a tax-funded non-means-tested system.

The TUC welcomes the overall shift in approach in the Green Paper, marking the move from an eligibility-based model providing support to only those in most need, to one where everyone is entitled to some care and support.

In this section we look at the pros and cons of the different funding options considered in the Green Paper. It is, however, difficult to comment in great depth on the funding options put forward without detailed costings for each of the systems proposed. We can only comment on the broad principles of each option and the main implications for working, disabled and retired people. However, it must be stated that we would have liked to have see the Big Care Debate focus on questions about the share of GDP the country wished to see spent on social care and how that should be divided between state and individual contribution, in addition to the questions about the funding options. Real reform of the social care needs to start from first principles about the level of resources the country is prepared to invest.

This last point is also linked to another major concern with the Green Paper. We feel that the question of quality of care was missing from the debate and in particular, the contribution of the workforce to quality care. The future of social care will rely heavily on the recruitment and retention of high quality social care staff, yet there has been little consideration in the Green Paper of either the importance of their role, or the cost implications of ensuring a high quality workforce.

One final point applies to all the funding options, rather than any individual option. The Green Paper raised the possibility of 'integrating some elements of disability benefits, for example Attendance Allowance, to create a new offer for individuals with care and support needs'. There was an immediate response from benefit claimants, terrified of losing their benefits, which led to a clarification from the Secretary of State - 'categorically' insisting that the Government has 'ruled out any suggestion that DLA for the under-65s will be brought into the new National Care Service.'

This is not such a concession, given that the plans for social care focus on care for people over working age; the money for reform is to come from current spending on social care for that age group, plus the budget for Attendance Allowance (only paid to over-65s) and Disability Living Allowance for that age group. The TUC is concerned that the 1.5 million older people who receive Attendance Allowance and the three quarters of a million over-65s who receive DLA will be extremely concerned about this proposal - though it should be admitted that the independent review of the Scottish policy on free nursing care accepted the need for a fundamental review of all the key strands of social care funding, including AA and DLA (care component).

The proposal is sometimes justified on the grounds that these benefits pay for care costs, so it's simply a matter of transferring funding to a different budget. This is not accurate - the people who qualify for these benefits and the people who qualify for social care are different groups. In February, more than 270,000 pension age claimants of DLA received the care component at the lower rate and more than 100,000 qualified for the mobility component at the lower rate; it is unlikely that they would qualify for social care services. Many of the 259,000 who qualify for the middle rate of the care component (and even some of the 800,000 who qualified for the higher rate of the mobility component) would also be likely to be excluded. More than 700,000 people receive AA at the lower rate and they would risk being among the losers from this change.

One of the few progressive changes to the benefit system in the mid 1990s was the introduction of the lower rates in DLA. The Government of the day may well have believed that this was a cheap option, but it turned out to be a major advance, helping disabled people with impairments at the lower end of the spectrum to meet their extra costs, and raising the income of hundreds of thousands of vulnerable people. These are not groups who are getting benefits they shouldn't, they are an important element of the poor, and they rely on their DLA. Today, £5 billion is spent annually on the lower rate of the DLA care and mobility components for pensioners. Bundling DLA and AA into the funding for social care that many of them will not qualify for will disadvantage a group that includes large numbers in poverty or on the margins; the TUC is therefore opposed to this proposal.

A tax-funded system has been ruled out in the Green Paper on the grounds that it places a heavy burden on people of working age. But the TUC believes that this is the most equitable option, ensuring that all generations make a contribution to the cost of care in later life since those people working age today will benefit from the system when they older and they in turn would be supported by the tax payments of those then working. This system would also benefit from the separation of the assessment of needs from decisions about the allocation of financial resources to meet those needs.

This option would match the principle of the National Health Service, providing universal care according to need and free at the point of delivery. This would place social care on the same footing as health care and go some way to end the problematic distinction made between the two.

In comparison to the insurance models proposed in the Green Paper, the TUC believes that funding would be better channelled through the tax and benefits system, rather than an insurance system. It would be more efficient and benefit from greater confidence and support from individuals.

We noted above the evidence that this option would be popular. The Scottish system, which is free at the point of delivery and assessed according to need, has now been in operation since 2002 and, according to last year's independent review of the system, 'has proved popular with the people of Scotland. (The number of complaints received by the Scottish Public Services Ombudsman is very low - in single figures per week. By contrast the Health Ombudsman in England has received complaints about the alternative policy there, numbered in thousands, and the NHS has already had to allocate payments in compensation for services wrongly charged approaching £200 million.)'

The independent review found that the additional cost of free personal and nursing care in 2007/8 was £89.4 million for free personal and nursing care in care homes and £79.6 million for free personal care at home. Of course, the National Care Service proposal is a much more thorough and wide-ranging proposal, and the Scottish independent review argued that the increase in the cost of social care would mean that a thorough review of funding (of the sort in the Green Paper) would needed for costs beyond a 5 year time frame.

The well being of a country is intimately related to the nature of its welfare state, and a non-means-tested universalist approach brings important advantages. As the World Health Organisation has noted:

'Generous universal social protection systems are associated with better population health, including lower excess mortality among the old and lower mortality levels among socially disadvantaged groups. Budgets for social protection tend to be larger, and perhaps more sustainable, in countries with universal protection systems; poverty and income inequality tend to be smaller in these countries compared to countries with systems that target the poor.'

The Green Paper argues that this option is unfair, because it places a heavy burden on people of working age. This is a curiously lop-sided argument; no one argues that children's services should be paid for by their families alone; services needed by people as they get older should similarly be provided by society as a whole.

All too often, the current debate is being distorted by notions about the alleged unfairness between the generations that has led to young people leaving university saddled with debt and unable to get their first step on the housing ladder because of distortions in the housing market that has disproportionately benefited older people. This claim ignores two important counter-arguments. First, today's pensioners have contributed to society throughout their working lives and did so willingly in the expectation that they would receive appropriate levels of care from the 'cradle to the grave' welfare state. This post-war promise has been steadily undermined in recent years and has led to people not knowing what support they are entitled to when the need arises.

Second, while some pensioners do benefit from generous, inflation proofed pensions, they are the minority who have enjoyed above average earnings during their working lives. There are still 2.5 million pensioners living in poverty, the UK has one of the lowest state pensions in the Western world, and one that is falling in value in comparison to average earnings. More than half of today's pensioners depend on the state pension as their main source of income.

The TUC continues to believe in the 'NHS model' - free at point of delivery and funded from general taxation. It is the simplest, fairest and most progressive way to fund a modern social care system.

The TUC does not support the partnership option. We accept that the expectation that funding should be a shared responsibility between the individual and the state would reduce the cost of this option and that it would provide clarity about what can be expected both in terms of individual and state contributions and the level of care. Clearer entitlements would allow people to plan ahead with greater understanding of the services on offer.

But these advantages are not enough to compensate for the substantial problems this option would entail accepting. As the Green Paper acknowledges, the partnership option is only based on the current level of supply. From the point of view of the equity of the system it is very important that it would not provide additional care to meet unmet needs. It will only provide financial help for those who pay towards the care they are already receiving. This does not therefore provide a fundamental reform of social care or care funding - people would still be forced to spend all their savings and sell their homes to meet their care costs. As it does not challenge or change the amount of resources allocation to social care, we cannot expect any improvement in quality or availability of resources from this model.

The Green Paper also sets out expectations related to the increased use of personalised care and individual budgets. This model would perhaps most create tension between funding and individual budgets since it is possible to envisage difficulties caused as individuals are required to pay for a proportion of their own care, then handed back money to administer their own budget.

The insurance model, which could work alongside the partnership model to allow citizens to top up their care through voluntary insurance, would build on the transparency of the partnership model, in that people would know how much they would be likely to pay for future care costs.

However, given the evidence of state pensions, with very few individuals able or willing to make additional contributions, it is difficult to see how people would be persuaded to contribute to voluntary insurance for social care. They would mean that people who do not take out insurance could potentially face the risk of high costs later in life. It would also be highly divisive, placing a stark division between those able and unable to afford insurance.

Of all the funding options outlined by the Green Paper, this one produced the most vehement opposition from trade unionists during our discussions. Private insurance relies on relating premiums to the level of an individual's risk. This means that disabled people, members of some ethnic groups, women and workers with atypical employment contracts (such as temporary workers) or certain employment patterns (such as some shift workers) would all have to pay higher premiums. This characteristic of private insurance is not only objectionable in itself, it would tend to force the highest costs on those least able to pay them, as all these groups have below-average incomes.

We also have grave doubts about the ability of the private insurance market to fill the gaps that would be left by the partnership model. As the Royal Commission noted in 1999:

'Left to grow without intervention, there seems little reason to think that private insurance will become more important in the UK than it has become over a 14-year period of development in America. At present only 4% - 5% of Americans have taken out LTCI, while 10% - 20% could afford to do so and 80% - 90% could not afford the cost in any event. Marketing through employers and partnership schemes with State Governments have been introduced in America and equity release products are available. According to expert witnesses, and the evidence cited earlier to a Senate committee, private insurance is not now, and is unlikely to become, the major way of funding long-term care in America. ...

'The Commission conclude that private sector solutions do not and in the foreseeable future, will not offer a universal solution. Even schemes for partnership can make only a limited contribution. Inevitably, of course, people may consider one of the many schemes available from the private sector to be worthwhile for them provided they can pay the premiums. Overall however, the funding problem cannot therefore be solved by the private sector.'

Compared with the other options the Government has said it is willing to consider - partnership and insurance - the comprehensive model has significant advantages. It would ensure that funding was made available for everyone and could lead to a better understanding for individuals of what they need to contribute over their lifetime. In common with the tax funded system, it would go some way to placing social care on the same footing as the NHS and allow a greater clarity about what constitutes health care and social care.

On the other hand, there are major concerns about the transaction costs involved in running either a private or state run insurance system. It is hard to justify the extra costs of administering an insurance-based system when compared with the NHS model. The TUC would also have difficulty in accepting on workers' behalf the burden of a £17,000 - £20,000 payment that people would have to meet on reaching the age of 65. This is, it must be admitted, less than the cost to individuals of the partnership or insurance models, but still a significant sum to require people to meet on retirement or to make a charge on their estate.

The comprehensive model could really only be operated on a compulsory basis, otherwise the scheme would face massive problems of adverse selection - only those who thought they might be likely to need social care would be likely to pay a voluntary premium, leading to much higher average costs per contributor. The Green Paper refers to the Japanese model, in which people are required, once they reach 40, to contribute to a long-term care insurance programme. Certainly, a scheme which required payments over the last 25 years of one's working life would be less of a burden than one which required a payment at 65, but provision which required payments over the whole of one's working life would be the least burdensome of all.

A key theme in the Green Paper is the prevention of people having to sell their homes to pay for care. It proposes that one option should be to allow people to pay any costs of care services or accommodation from their estate after death.

This would prevent people losing their family home and takes advantage of the near £1tn locked up in personal equity. However, there are numerous potential problems, including the very real risk of avoidance, particularly through the disposal of assets during life. This would be costly, both in terms of lost revenue and the administration involved. It is also unclear how this system would affect family members still living in the house.

Although the bulk of comments on the Green Paper have focused on the funding options, unions are just as exercised about whether local authorities should be able to determine the level of social care someone is entitled to and the way it is funded.

The advantage of this approach is that it would still go some way to ensuring that people's needs were met, wherever they lived, whilst allowing local authorities some flexibility to take into account local circumstances. This would allow local authorities to respond better to local cultural and geographical differences and needs and allow local democratic responsiveness in terms of the funding and delivery of social care.

For unions, however, the fact that local authorities would still be responsible for setting the actual amount of funding someone would receive is a major disadvantage. A part national, part local system would fail completely to eradicate the postcode lottery and people could still get different amounts of funding in different places.

We saw earlier that most of the participants in the 2008 debate favoured this option, and this was the preferred choice of trade unionists who took part in the TUC's discussions. The TUC views the national assessment and national rules on eligibility as the heart of the National care Service, and we would very much regret their abandonment.

Under a national system, the Green Paper states that it is likely that all funding for care would need to be raised nationally through taxation or insurance in the case of the comprehensive model, instead of some of it coming through council tax.

The amount of funding could be consistent or could vary according to location to take account of the different costs of care across England and would allow people to move around the country without having to be re-assessed. This would offer individuals a degree of certainty, but questions remain over the ability of national government to prescribe exact packages and budgets of social care that would be delivered locally. Several countries appear to rely on bands or categories of needs and this may offer a solution to the difficulty of identifying identical needs.

This system could to an extent insulate social care budgets from local political pressures and the possibility of cost-cutting as local authorities' role would be limited to administering funding and commissioning services. On the other hand, this model may not allow local authorities the same freedom to decide on local care priorities and respond to local circumstances as the part national part local system. However, as local authorities would continue to receive funding and hold responsibility for the delivery of social care services, there is still an important role in overseeing the quality of provision.

Some concerns have been expressed about the lack of flexibility in budgets and the inability to reflect local circumstances. However, central government could still set different budgets for the same needs among different areas to reflect different costs. They effectively do this currently by giving varying grants to local authorities partly because of variance in local costs.

In a 132-page Green Paper just one page is devoted to workforce issues. It is dangerous to assume that, once questions about the funding and structures have been addressed, then all the services that are needed will be 'on tap.' This is particularly true for the workforce. High quality social care services require well-paid, well-trained and well-motivated staff and it is vital that planning is put in now in order to deliver this for the future. The workforce accounts for 80% of all social care expenditure. In the UK, there are 957,000 care workers providing formal care to older people. The fact that 83% of these workers are women and 50.4% work part-time, alongside a reliance on migrant workers, poses many challenges. We need to ensure that higher standards of training and skills lead to better pay and status for care workers.

Working to Put People First: The Strategy for the Adult Social Care Workforce in England did little to address some of the key questions about the future of the workforce, particularly in relation to the growth of individual budgets and the use of personal assistants.

There are many lessons from other parts of the public that could be adapted and applied to social care. For example, the social care workforce shares many similarities with the children's workforce, in terms of diversity of provision and skills issues. We would therefore promote the adoption of a similar approach to the Children's Workforce Development Council (CDWC) in delivering the Every Child Matters outcomes. The CDWC produced a national toolkit framed in order to allow the strategy to be developed locally to suit local circumstances. The NHS also affords a positive example with its Knowledge and Skills Framework, which provides flexible and transferable career pathways to aid progression from support roles to professional qualification.

A case study undertaken for the Public Services Forum Learning and Skills Task Group into adult social care highlighted the workforce implications of personalisation and particularly individual budgets. It warned that 'a significant proportion of employment is expected to move out of the current regulated and registered environment, which supports the acquisition of skills, to one where the limited funding for the acquisition of qualifications and little evidence that it is thought necessary.'

A two-tier workforce is emerging with a regulated professional workforce alongside a casualised personal care sector. All too often, casualisation and marketisation is leading to a serious decline in employment standards, and this has serious consequences for morale and turnover. The differences in pay rates between the public, voluntary and private sectors are stark and the private sector is the lowest payer by some distance. In that sector the differential between 'care worker' and 'senior care worker' is the lowest, suggesting little incentive for workers to undertake training (and limited opportunities for career development).

Median pay rates by sector (source NMDS-SC, Dec 08 - Feb 09)[40]

NMDS-SC job role	Private	Voluntary	Statutory	All sectors
Care worker	£6.30	£7.04	£6.80	£6.56
Senior care worker	£6.75	£8.34	£9.11	£7.00
Registered manager	£26,000	£26,734	£28,270	£27,175

Unsurprisingly, care worker turnover rates are highest in the private sector - 23.6% - and considerably lower in the statutory sector - 9.6%.

There are also very real concerns about the growth of agencies in the personal care market, to which people understandably turn in order to avoid the responsibility of being an employer. Agencies take a fee for supplying a personal assistant, leaving even less money from the personal budget allocation available to pay the worker. There are also concerns about the lack of pension and maternity provision and sick pay that need to be addressed now before personalisation is rolled out any further. High quality services will not be possible with a workforce beset by high turnover, poor training and pay and low morale.

The TUC urges the following measures to make sure that entirely preventable workforce issues do not undermine the National Care Service:

Partnership working with trade unions to define and plan for the workforce of the future.

The commissioning process must be adapted to ensure a well-rewarded, well-motivated workforce that will provide high quality services in the future. Pay and employment conditions must be a key part of the whole commissioning process.

There should be a national career pathway model to support entry and progression based on the Knowledge and Skills Framework of Agenda for Change.

Employers should meet the cost of the Vetting and Barring Scheme.

Registration should be extended to personal assistants in order to protect both employer and personal assistant. The registration process for all health and social care providers should require pay, conditions and employment practices that are of sufficient quality to recruit and retain competent staff.

There should be a Code of Practice on the employment of Personal Assistants, alongside a framework for pay and conditions

The TUC is a strong supporter of a National Care Service. We believe that the proposed national rules on assessment and eligibility are the answer to the muddle and injustice that characterise the current system. We also strongly support the Green Paper's emphasis on helping people to remain in their own homes for as long as possible.

We believe that the funding option that is truest to the spirit of the rest of the Government's proposals is the NHS model. This option is popular, simple and fair.

We also want to see a National Care Service that invests in its staff, in their skills and which works in partnership with their unions. We want to see a system that you would be happy to have caring for you, and which you would be happy to work for.

Taken from information on the Whitehall II website: http://www.ucl.ac.uk/whitehallII/index.htm

Equality Trust website: http://www.equalitytrust.org.uk/why/evidence

'Income Inequality and Health: a review and explanation of the evidence', Wilkinson, R. G., & Pickett, K. E. (2006). Social Science & Medicine, 62(7), 1768-1784.

'The global impact of income inequality on health by age: an observational study', Danny Dorling, Richard Mitchell and Jamie Pearce, British Medical Journal 2007; 335:873 (27 October).

Mental Health, Resilience and Inequalities, Lynne Friedli, WHO Europe, 2009, p 35.

Data taken from the Institute for Fiscal Studies' Inequality and Poverty Spreadsheet at http://www.ifs.org.uk/fiscalFacts/povertyStats on 10/30/2009 4:18 PM. Inequality is measured by the Gini coefficient on an after housing costs basis. Data to 1993-4 are from the Family Expenditure Survey for GB, data from 1994-5 to 2001-2 are from the Family Resources Survey for GB, data since 2002-3 are from the Family Resources Survey for the UK.

Eurostat data, downloaded from http://epp.eurostat.ec.europa.eu on 30/10/2009 17:05. 2007 data were the most recent for which a UK figure was available. Figure for Portugal is provisional. Income is equivalised disposable income.

Poverty, Parenting and Social Exclusion: educator's guide, SCIE, 2008, p 2.

This discussion uses the Government's definition of poverty: living in a household with an equivalised income below 60 per cent of the median on a before housing costs basis. Data are taken from Households Below Average Income (HBAI) 1994/95-2007/08, DWP, 2009, chapter 5.

This group includes households with one or more workless person aged 60 or more.

Data are taken from Households Below Average Income (HBAI) 1994/95-2007/08, DWP, 2009, table 6.9ts.

Ibid, p 10.

Cutting the Cake Fairly, CSCI, 2008, p 26.

Cutting the Cake Fairly, CSCI, 2008, p 25.

Care Contradictions: putting people first?, Counsel and Care, 2008, p 5.

Self-actualisation is the pinnacle of Maslow's famous hierarchy of needs (Motivation and Personality, Abraham Maslow, 1954, passim), and it has often been described as the polar opposite of dependence. In the past, some commentators have therefore argued that frail elderly and disabled people with significant impairments (who are necessarily dependent upon care services) are incapable of achieving it. The disability movement has forced through a re-evaluation of this issue, and the TUC agrees that people who rely on care services should still be regarded as independent, provided they have powers of voice and exit in regard to these services.

Transforming Social Care: Changing the future together, Peter Beresford and Frances Hasler, Centre for Citizen Participation, 2009, p 14.

See the evidence from People First, Changing Perspectives and Values into Action to the Joint Committee on the Draft Mental Incapacity Bill [2003]: http://www.publications.parliament.uk/pa/jt200203/jtselect/jtdmi/189/3102101.htm and follow the links to oral and written evidence.

'Engagement Findings', COI, Ipsos MORI and Synovate for HMG, 2009, available at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_103075.pdf

Ibid, pp 14 - 17.

Ibid, p 60.

Reported in the Green Paper, pp 88 & 90.

Green Paper, p 91.

'Engagement Findings', COI, Ipsos MORI and Synovate for HMG, 2009, p 53.

Ibid, p 54.

Ibid, p 63.

Ibid, p 53.

http://www.youtube.com/watch?v=gnVB6-qf_o8&feature=youtube_gdata section on the National Care Service begins at 0:44:44.

Green Paper, p 15.

Andy Burnham MP, speech to the National Children and Adult Services Conference, 22 October.

DWP Information Directorate: Work and Pensions Longitudinal Study. Figures for February 2009.

The Independent Review of Free Personal and Nursing Care in Scotland, Lord Sutherland, Scottish Government, 2008, para. 117. Downloaded from http://www.scotland.gov.uk/Resource/Doc/221214/0059486.pdf on 02/11/2009 18:56.

DWP Information Directorate: Work and Pensions Longitudinal Study. Figures for February 2009.

Calculated from Ibid.

The Independent Review of Free Personal and Nursing Care in Scotland, Lord Sutherland, Scottish Government, 2008, p 4.

The Independent Review of Free Personal and Nursing Care in Scotland, Lord Sutherland, Scottish Government, 2008, para. 138.

Closing the Gap in a Generation: health equity through action on the social determinants of health, final report of the Commission on Social Determinants of Health, World Health Organisation, 2008, p 10.

With Respect to Old Age: long term care - rights and responsibilities, report of the Royal Commission on Long Term Care, 1999, para.s 5.38 and 5.40.

www.cabinetoffice.gov.uk/media/102175/ADULT_SOCIAL_CARE_REPORT.pdf

UNISON submission to the House of Commons Health Committee inquiry into 'Social Care in England', 2009, para. 2.7.

Ibid, para 2.9.

All working-age adults without children

No full-time, one or more in part-time work

Workless, one or more unemployed

Workless, other inactive

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