The time has come for real reform of long-term care

They say that reforming long-term care is a bit like trying to tackle climate change. Deep down, many of us know there’s a big issue here and that something fundamental will eventually have to happen. However, it’s a long-term problem, most of the solutions are unpopular, and it’s often easier to leave to a future government to sort out rather than take the pain now – particularly when an election isn’t too far away...

For all these reasons, reform of long-term care has been much debated over time, but with little practical action. We’ve seen the 1999 Royal Commission (implemented in Scotland but rejected in England), a review by Sir Derek Wanless (his recommendations about NHS funding were implemented; his conclusions around long-term care weren’t) and a flurry of proposals in the run up to the 2010 election (when it was arguably too late in the electoral cycle for any of the proposals to be implemented). When the Coalition promised another review, everyone groaned – we know what the problems are; we just don’t agree what to do about them.

As the Queen announced the Care and Support Bill in parliament, it was interesting that she described it as a policy to prevent older people from having to sell their homes to pay for care. The Bill does a number of things, but this might not be one of them. The current legal framework is very messy and outdated, and the Bill will tidy this up and modernise it. It also contains welcome measures around the provision of advice and information, the portability of assessments and scope to defer payments for care until after you’re dead (hence the way the Queen described the Bill, presumably). This latter approach already exists in a number of authorities, but will now be universal (albeit that paying interest on such schemes in future may make them a less good deal than at present).

However, the central issue has been proposals to cap the costs that people pay for care at a suggested rate of £72,000. This seems good news at first glance, but the limit chosen may well be far too high to make a difference to most people (and a long way off the £35,000 suggested by the Dilnot Review). At £35,000, there may have been an incentive for more people to prepare for their old age and plan ahead as to how they might meet such costs (whether by saving, via an insurance policy or whatever). At £72,000, many people might decide it isn’t worth it – thus defeating the primary purpose of the cap. Since this will only apply to people’s care costs, they will also continue to be liable for any living and housing costs, and these could prove significant. This was also an issue in Scotland, where some people assumed they would receive ‘free care’ rather than ‘free personal care’ (and the difference in wording is crucial).

Perhaps more significant is the proposal to increase the threshold at which people start to become eligible for some form of state contribution towards their care costs (from £23,250 at present to a suggested £123,000). In some areas of the country, this will bring many more people into the system, and it will need to be carefully implemented – particularly at a time when local government budgets are already stretched to breaking point.

However, the key risk is that most of this misses the point. Despite a technical debate about different funding models, we don’t seem to have managed a national debate about how much we really value older people in our society, what sort of life we want to have together and how much we’re all prepared to pay for this. Most of us know that if we want something badly enough, we’ll have to pay for it – either when we’re alive, when we’re dead or through some combination of the two. Rather than confront this, we’ve leapt straight into the debate about funding models and lost sight of the bigger picture. As a private individual, I’ve often asked why long-term care can’t be provided free at the point of delivery (like the NHS). The answer is nearly always that this would be ‘unaffordable’ (which sounds initially like an economic argument, but is actually a political statement: something is only unaffordable if we’re not prepared to pay for it). Actually, we could fund all kinds of improvements in older people’s services if we really wanted to - and we could do so tomorrow. However, we’d have to make some very difficult decisions about what not to do in order to free up the necessary money.

For too long older people have been forced to use long-term care that many of us think isn’t good enough and that isn’t funded fairly. The Care and Support Bill could be a chance to do something about this, but it could just as easily go the way of previous reforms and not deliver the more fundamental change that many think is needed. After the erratic weather we’ve had this year, perhaps some of the long-term issues we tried to put off till tomorrow actually need sorting now?

Professor Jon Glasby is Director of the Health Services Management Centre, University of Birmingham. This article has recently appeared on the Guardian Professional website.