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BOARD MEETING - 16 SEPTEMBER 2009
CQC RESPONSE TO SHAPING THE FUTURE OF CARE TOGETHER
GREEN PAPER
PURPOSE
1. To brief Board Members on the content of the Shaping the Future of
Care Together Green Paper; also, to inform Board Members of
planned and on going actions to promote awareness of and collect
evidence to respond to the Green Paper; and to seek Board Members’
views and comments on a number of key points to help shape the CQC
response.
RECOMMENDATION
2. This paper recommends that Board Members note the briefing and
actions to communicate the issues and engage stakeholders and staff
across the Commission in contributing to the Green Paper response.
Further, that Board Members consider and comment on questions
about a number of key issues in the consultation to help shape our
response.
BACKGROUND
3. The Shaping the Future of Care Together Green Paper, published on
14 July, sets out the Government’s vision for a new future system of
care and support, to be called a National Care Service. A briefing on
the Green Paper content and consultation questions is attached for
information at Annex A.
4. CQC has a key role in providing evidence to contribute to and influence
the debate on the future of social care, as well as in using our unique
perspective to assess the impact or potential impact of proposed
system changes and what these may mean in respect of outcomes for
people who use services. The consultation runs until 13 November
and CQC will submit a response within this timescale.
5. The planned process to raise awareness of the Green Paper, the
issues raised, and to seek responses from stakeholders including staff
is attached at Annex B.
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6. The Green Paper has strong links with two areas of work which are
progressing in parallel and being considered by CQC and to which we
will formally respond:
(i) a Department of Health consultation on revised guidance to
Local Authorities about social care eligibility criteria, which
runs to 6 October; and
(ii) the Health Select Committee Inquiry into the future of social
care services, which is seeking written evidence by 1
October. No dates have yet been set for calls to give oral
evidence.
7. The Government have stated they intend to produce a White Paper,
containing detailed proposals for implementing the new National Care
Service from 2014.
8. The Conservative response to the Green Paper is that there should be
serious, costed proposals, and that the paper is “long on options and
short on costs and conclusions”. They, too, favour a partnership
approach which: allows people to protect assets and inheritance; is
integrated with extra-care support to help people maintain
independence; includes work with local authorities to ensure high and
consistent standards in care homes; and is financially sustainable.
9. The Liberal Democrats response is to support universal entitlement
with a focus on prevention and the availability of advice and support.
In addition, they favour reablement following hospital discharge; and
giving carers and care workers more dignity and respect. They are
calling for a cross-party commission to achieve consensus and to
commit any incoming government to urgent reform.
10. As the regulator for health and social care it is envisaged that the CQC
response should position itself to address the issues of reform of the
system rather than those of funding as set out in the discussion paper.
KEY ISSUES
11. The content of the CQC response will be developed over the coming
weeks, taking into account feedback from staff and other stakeholders.
Views of Board Members on a number of key issues would be
particularly welcome in shaping the response:
(i) The urgency in addressing the issue: the evidence CQC has
inherited about people’s poor experience of care services
when they have not met eligibility criteria is compelling. The
likelihood is that in the short term people’s experiences will
worsen before they improve, as criteria are more likely to
tighten than be relaxed. Do Board Members have
particular views on this and the urgency with which the
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issue of reform should be addressed which they would
like to see reflected in the consultation response?
(ii) Funding options: the Green Paper sets out 3 main funding
options, having ruled out a further two. Do Board Members
feel we should or should not take a view on the funding
options?
(iii) Flexibility in support: one of the key questions is whether
people should get the same care and support wherever they
live; or whether it is acceptable for people with the same
needs but living in different areas to receive different levels
of care and support. What are Board Members’ views on
this issue?
(iv) Universal right to assessment: one of the key expectations
that all people will have under the National Care Service is
the right to a national assessment, with care needs assessed
in the same way across the country. Board Members are
asked to endorse this proposal.
(v) Role of Social Care Institute for Excellence (SCIE): the
Green Paper proposes that an independent organisation
establish the evidence base for care and support and advise
on what works best in terms of interventions which are most
effective and what gives best value for resources. In addition,
the organisation could help design a social care evidence
and research programme to assess gaps in the evidence
base and produce evidence as necessary. The paper
suggests the role could be given to an existing organisation,
such as SCIE, or a new one. What are Board Members’
views on this and on whether part of this role could be
performed by CQC?
LINK TO STRATEGIC AND CORPORATE PRIORITIES
12. There are clear links between all CQC’s Strategic Priorities and the
Green Paper, particularly the proposal to build a National Care Service.
The Green Paper consultation supports: quality care; person-centred
care; and joined-up care
EQUALITY, DIVERSITY AND HUMAN RIGHTS IMPLICATIONS
13. Engagement plans will take into account Diversity issues to ensure that
a broad range of stakeholders, including people who use services, their
carers and families, as well as CQC staff, are able to contribute their
views to the consultation.
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NEXT STEPS
14. Board Members’ views and comments will be taken fully into account in
the development of the content of the consultation response. Board
Members will be given the opportunity to see and comment on the draft
response before it is submitted within the deadline of 13 November.
RECOMMENDATION
15. This paper recommends that Board Members note the briefing and
actions planned to communicate the issues and engage stakeholders
and staff across the Commission in contributing to the Green Paper
response. Further, that Board Members consider and comment on
questions about a number of key issues in the consultation to help
shape our response.
ANNEXES
16. Two annexes are attached, as follows: Annex A provides a briefing on
the Green Paper consultation, including the questions on which a
response is sought. Annex B sets out plans for consulting and involving
staff and other stakeholders and seeking their contributions to feed into
the CQC response.
Name: Ronald Morton
Title: Strategy Development and Innovation Manager
Date 25 August 2009
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Annex A
SHAPING THE FUTURE OF CARE TOGETHER
A Government Green Paper on funding a National Care Service
Summary
The Green Paper, Shaping the Future of Care Together, is a consultation
document about how care and support services in the future will be provided,
arranged and funded. It proposes the establishment of a National Care
Service (NCS), with the potential to be as significant as the launch of the
NHS. The NCS would be the umbrella name for all bodies delivering care
services. The Green Paper presents three options for possible models of
funding and seeks people’s views on these. It also sets out the government’s
view that there should be universal entitlement to services such as
information, assessment and advocacy, with the nub of the paper focused on
establishing the boundary from which people have to pay. In short, it is about
working out how much people will pay for any care and support they may
need in the future, as well as how and when it will be paid for.
Background
What is social care?
Social care can be defined as the range of services provided by local
authorities, the independent and voluntary sectors to people in their own
homes or in care homes. This also includes services such as day centres
which assist and support people with their daily lives. The type of care given
depends on the needs of the individual. This may cover a range of basic
needs such as washing, dressing, eating or going to the toilet.
Who pays for it?
Unlike the NHS, social care is not a universal service free at the point of use.
Anyone with assets over £23,000 (such as their savings and/or the value of
their house) must pay for all their own social care, irrespective of where they
live, including in a nursing home. Care needs are determined by an
assessment, and a separate means-test decides if a person pays for all, some
or none of the care package. In effect, most people pay for all their own care.
Why reform now?
Demographics - increasing numbers of older people, many with long term
care needs, coupled with fewer people of working age - will make the current
funding arrangements for care and support unsustainable. Estimates suggest
that a gap of over £6 billion in public funding will emerge over the next 20
years, when 1.7 million more adults than now will need support. A new
settlement between the state and the individual is therefore required to ensure
that people can receive the care they need when they need it.
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Unfairness – the current system is seen to be unfair for the large numbers of
people who make provision for themselves. There is also little offered to
people in terms of advice and support, at a time when people are expected to
make expensive and life-changing decisions about themselves or a relative
often under great pressure and stress.
Inconsistency – there are significant variations in standards and quantity of
support offered by councils across England. People often do not know what
to expect and entitlements change if they move to live in another area.
Use of Resources – the current system can make poor use of its limited
resources, with support targeted to those with the highest levels of need.
Money could often be better spent on preventive services or rehabilitiation, to
help keep people more active, independent and healthy for longer. This
would help prevent costs being passed to the NHS.
What does the Green Paper propose?
The establishment of a National Care Service for England encapsulates the
vision for the future. It will be fair, simple and affordable for everyone,
underpinned by national rights and entitlements but personalised to meet
individual need. Dignity, respect and human rights will be fundamental
elements.
In future, people should be able to expect 6 things around care and support:
1. prevention services – eg. people leaving hospital who need care and
support for the first time will have the right to re-ablement services at
home for six weeks
2. national assessment – people will be assessed in the same way
wherever they live
3. a joined-up service – services will work together and be joined up
4. information and advice – this will be easily available and let people
know what care they can expect and how quickly it will be provided
5. personalised care and support – services will be based on personal
circumstances, giving greater choice and control, including over own
care budget
6. fair funding – exeryone who qualifies for care and support from the
state will get some help in meeting the cost of care
Consultation question 1: (a) is there anything missing from the above
approach?
(b) how should this work?
Three major changes are seen as necessary to move forward:
1. More joined-up working between health, housing and social care
services, and between social care and the disability benefits system.
Structural change may not be necessary: how managers and staff work
can enable integration.
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2. A wider range of services in care and support, with councils managing
the market in their areas
3. Better quality and innovation – everybody using services should expect
and receive high quality services. People working in care services will
be better supported to develop skills and build a career. An
independent organisation should advise on quality and best value, as
well as guide decision-making from commissioners and the public
about which services to use.
Consultation question 2: to make the National Care Service work services will
need to be joined up, be of high quality and give people choice around the
care and support they receive. (a) do you agree? (b) what would this look like
in practice? (c) what are the barriers to making this happen?
Proposed funding models for the future National Care Service
The Green Paper makes clear that there is a role for the state going forward
in the future funding of national care. The underlying principle is that everyone
who qualifies for care and support from the state should get some help in
paying for it. However, the proposed funding options relate only to those who
need care and support after retirement. The Paper is clearly mindful of
discrimination but makes clear that costs of care and support to people who
are disabled early in their lives will have to continue as people in this group
generally have fewer resources and less capacity to generate resources.
The three funding models proposed for comment are set out in the table
below.
Option
Partnership Everyone entitled to a set proportion
of care costs on a sliding scale
depending on their means. The
contribution from the state would be
between 25 -33% but more for those
on lower incomes.
Insurance As for the partnership model (25 –
33%) but goes further through
additional insurance if people take
this up. The state could work with the
private insurance market and people
could pay in different ways:
Instalments;
Lump sum;
Before retirement;
After retirement;
After death
Comprehensive Everyone pays into state insurance
scheme after retirement (unless they
cannot afford it) so that care is free
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for all when needed. There is a free
care system alongside this for
working age people.
The three preferred options are therefore Partnership, Insurance and
Comprehensive. The partnership option is the one which Wanless set out in
the Kings Fund publication on the future of social care funding (2006).
Two further models were considered – people paying for themselves; and a
system funded through general taxation – but ruled out on grounds of inequity
and the burden placed on people of working age
Consultation question 3A: Which of these options do you prefer and why?
Whichever system results, the Government wants it to be fair and universal,
so everyone who qualifies gets care, irrespective of where they live.
However, the system needs to have local flexibility which takes into account
local circumstances and what local people need. So national consistency
needs to be balanced with local situations.
Moving to a universal system also has implications for how care is funded.
The Government propose a standardised national needs assessment
process, with centrally-set levels of need determining access to state funding,
and centrally-set limits on the proportion of a person’s care package the state
would pay for. This leads to two different options for raising and distributing
money to pay for care:
1. A part-national, part-local system
People would know they were entitled to having needs met, that the state
would pay a proportion of the cost, but local authorities would decide how
much a person received, taking into account local circumstances. This could
mean, for example, a disabled person knowing the level of support they were
entitled to in their area, although if they moved the amount of funding could
vary. If local authorities set funding levels, the advantages would be they
could respond to local conditions and encourage new kinds of care and
support in their areas. The disadvantage is that people in different areas
could get different amounts of money, which could be seen as unfair.
2. A fully national system
The Government would decide how much funding people should get, instead
of local authorities. This could be consistent across England, or could vary to
take into account different costs of care in different areas. The advantage
would be the system would be easy to understand and plan for. People could
move around and receive the same amount of funding. The disadvantage
would be for local authorities to tailor care packages in a personalised way,
especially where local circumstances and costs varied from area to area. The
system would be more rigid. This system would also mean the end of the
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current arrangement where local authorities can fund care over and above
government funding by using money from council tax. Funding would
therefore need to be raised nationally through national taxation rather than
through council tax.
Under either of the above systems, local authorities would still have a pivotal
role in delivering care and support: undertaking assessments; providing
information, advocacy and care management; providing and commissionnig
services; managing the market of care and support providers; and deciding
how care services are delivered locally; acting as the channel for state
funding.
Consultation question 3B: Should local government say how much money
people should get depending on the situation in their area, or should national
government decide?
Residential Care Costs
Those who can afford it will continue to pay residential care costs. The
proposal is that there should be a universal deferred payment mechanism
which allows for costs to be charged to an estate after death. Such an
approach means that people will not have to sell their properties whilst alive to
pay for their care.
Timing
The consultation runs until 13 November 2009.
The Government state they plan to publish a White Paper some time in 2010
before the General Election. There will not be time, however, to pass
legislation to take this forward until after the Election. Also, any new system
will take time to phase in, with 2014 being given as the earliest date for
starting implementation.
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Annex B
The strategy for informing people and gathering evidence to shape the CQC
response is as follows:
(i) Inform staff about the Green Paper and issues through Chief
Executive update – issued in August
(ii) Issue joint letter and briefing to all staff from Chairman and
Chief Executive (finalising). The letter:
(a) Encourages staff to attend one of 36 Department of
Health regional consultation events where possible
(b) Asks staff to contribute individual responses to the
consultation based on their knowledge and
experience of care services
(c) Suggests staff spread news of the Big Care debate
to their circles of family and friends to help maximise
impact and awareness of issues
(iii) Create a dedicated mailbox to gather staff views on the
consultation
(iv) Set up a deliberative event for Chairman and Board
Members to host to debate the issues raised in the Green
Paper
(v) Plan to engage with stakeholders to gain views and evidence
to feed in to CQC’s response
(vi) Make links to the related consultation on eligibility criteria,
which will underpin the proposal for a national assessment,
as well as the Health Select Committee inquiry on social care
(vii) Respond to consultation by deadline of 13 November
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