Policy responses and statements
- Name of organisation:
- Department of Health
- Name of policy document:
- Green Paper: Shaping the future of care together
- Deadline for response:
- 13 November 2009
Background: This Green Paper sets out a vision for
a new care and support system. More and more of us are living longer,
but more of us will also live with needs for care and support. The
current care and support system was designed in the 1940s and we need
to develop a system that fits our needs in the 21st century. We need
a system that is fairer, simpler and more affordable for everyone.
To build this, we will need to make some big decisions and reach agreement
across society on the right way forward for England. So, this is the
beginning of a Big Care Debate.
The case for change:
Our society is going through dramatic change. We are living longer
and leading more active lives, and we expect our public services to
allow us to live our lives the way we want to. But this presents issues
which public services need to address. Care and support affects everybody.
We may need care ourselves, know someone else who does or help pay
for care and support through our taxes.
We know that, despite many improvements over the years, the system
is still regarded as unfair. Many families who have saved all their
lives find themselves facing high costs for care and support for themselves
or their loved ones. We know that it will not be able to cope with
future pressures in its current form and we need to reform the funding
system.
A National Care Service:
Building on what people said that they wanted from services during
last year’s engagement programme, this Green Paper sets out a
vision to build a high-quality National Care Service that is fair,
simple and affordable. People want to be treated fairly. We want a
system whereby people get the support that they need wherever they
are in the country. The system needs to be simple. People want to know
exactly what to expect from the system and what they need to do in
order to get help.
Care and support needs to be affordable for everyone. At the moment
surveys tell us that more than half of people think that care will
be free. But it is not. Care and support costs can be very high: a
65-year-old can expect to need care costing on average £30,000
during retirement.
People have said that everyone in society shares the responsibility
for making sure that people receive the care they need, but the funding
of care and support generated some of the most heated discussions in
the engagement process. People were passionate that any new funding
system should be fairer, proportionate to what people could afford
and easy to understand.
This Green Paper outlines the vision for a National Care Service and
what people should expect from it. It asks for views on some difficult
choices that need to be made for this vision to become a reality and
to ensure that there is enough funding for the system to be able to
deliver the kind of care and support that we, as a society, should
be aspiring for. The proposals in this Green Paper would bring about
some of the most fundamental reforms ever in care and support.
COMMENTS ON
DEPARTMENT OF HEALTH
GREEN PAPER: SHAPING THE FUTURE OF CARE TOGETHER
The Royal College of Physicians of Edinburgh is pleased to respond
to the Department of Health’s Green Paper on Shaping the
future of care together.
Our comments have been collated following input from interested Fellows
who are based in England. In general terms, we welcome this initiative
because the ageing population is going to require increasing effort
and expensive. We would offer the following comments for your
consideration.
We fully endorse the stress put upon the need for preventative services
as a means of reducing morbidity and disability in the ageing population. However,
the aspiration could perhaps be fleshed out, with more detail provided
on how these issues are going to be addressed. We are aware of
initiatives over the past few years in respect of primary care management
of conditions such as hypertension or diabetes. However, we still
feel that there is a need to develop more proactive screening programmes
for the elderly using multi-disciplinary approaches. We believe
that, in order to achieve this realistically, elderly medicine will
require major investment to develop appropriately targeted clinics
and services, as rehabilitation is only effective when there is a firm
medical diagnosis plus access to all the specialist skills required.
We welcome the proposal for national assessment as a method of eliminating
health service inequalities across England, although our concern is
that this might lead to another level of bureaucracy being imposed. Personal
experience from some of our Fellows suggests that this is a real concern
as all too often patients, having been fully assessed by the specialist
hospital team, are reassessed once more by the PCT merely to confirm
a correct assessment. We also worry that a national service
must take account of the relative wealth and costs of care in different
parts of the country. We would also comment that there is likely
to be an increasing burden from dementia in addition to that from physical
disability. At present, continuing health care funding comes
from Primary Care Trusts and this may be unaffordable in the long term.
In respect of the aspiration to a ‘joined up service’,
we would welcome this because boundaries are somewhat artificial in
the context of patient requirements. We are concerned that there
is little mention of hospital services in this context because, although
secondary care sees only a relatively small proportion of such patients,
these are often the most complex cases which will consume the most
health care resources in order to be supported adequately in the community.
The concept of the same proportion of costs being met wherever the
patient lives is good in theory but will lead to a greater budgetary
pressure in areas where health care is more expensive. This must
be taken into account to support the concept of fair funding. We
believe that the National Single Assessment Process, when applied locally,
has had only limited success (perhaps because people’s needs
change), and we would urge that documentation needs to be concise.
The aspiration (page 55) states that the Government should play a
major role in making this available, which is somewhat at variance
with the aspiration to encourage local initiative with innovation (pages
53 and 58); clarification is required.
The aspiration for carers to be recognised as experts by 2018 is,
we feel, laudable but neither realistic nor achievable. Likewise,
the provision of personal budgets is likely to lead to an increased
bureaucracy as so many purchasers will be involved, and the avoidance
and detection of fraudulent claims is likely to be problematic.
We feel that consultation Question 1 is not really a question as the
decision has already been made that there will be greater central control
and encouragement to local innovation, and we wonder whether these
are compatible aims.
We feel that the concept of a renamed National Care Service fits well
with the philosophy of the NHS and would support it.
We would comment that the example given for ‘joined up working’ (the
local Poole POPP pilot) seems more an argument for the national funding
of local work. Thus, in respect of consultation Question 2, we
support a joined up service of high quality and choice. We also
believe that serious consideration should be given to the re-introduction
of the DHSS in order to avoid disagreement as to who is responsible
for what between health and social services. This would enable
health and local authority care to be amalgamated. Whilst this
might cause some concerns in respect of representation, accountability,
and control, links along the lines of those already established for
foundation Trusts could be developed.
In respect of personalised care and support, we believe that the vast
majority of elderly people would prefer to remain in their own environment
with support from their family and a care package. Whilst at
times this involves a risk, we believe most elderly people would accept
that risk compared to the alternatives. We would also contest
the comment on page 65 that care at home is cheaper than residential
care; we believe that this would be inaccurate in a significant part
of England as an important proportion of the costs of 24-hour care
(residential/nursing) is dependent upon property prices which, of course,
vary hugely across the country.
In response to consultation question 3 in respect of funding, we accept
that there are indeed complex issues as demonstrated by the fact that
no consensus appears to exist at Government level. We believe
that Scotland does have an effective system but doubt that this could
be afforded in England. We feel that an insurance based system
would be fairest, aimed particularly at care and accommodation rather
than health, in order not to break the political tenet of “health
free at the point of delivery”. We also agree that it is
indeed an injustice that those who have saved throughout their lives
are penalised for their prudence in contrast of those who have not
done so. We would still support a charge for board and lodging
since even a person living at home would have to pay these costs. We
would not have a specific preference as to the method of funding, which
we feel is outwith the remit of a College, but would urge that any
system that is installed is fair, transparent and protects the vulnerable. We
rather suspect that the Government will require to underwrite an insurance-based
system if that is what is decided upon. It might, for instance,
be possible to separate insurance cover for health care from that for
accommodation.
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[13 November 2009]
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