Most of us are well aware that many attempts over the years to improve the scope and quality of social care for the elderly and disabled have failed on the altar of funding. Undoubtedly the costs are high. My mother received full-time in-house care from the private sector during the final two years of her life and was paying over £6,000 a month. And that was ten years ago. The service was very good, but when you consider that it involves careful selection, vetting and recruitment of staff as well as their training and supervision on top of their wages, when typically they were working 24/7 for two weeks on and two weeks off, that is not surprising. One of ours flew back to her family in Malta every two weeks! And I don’t know what profit margins the agency was making but I suspect they were high given levels of demand.
However the danger here is we become fixated on finding the money and overlook serious structural faults in the system. Public sector care is mainly outsourced, and the widespread problem with outsourcing is that the person receiving the service is not the person paying the bills. So if the service is substandard the bills still get paid anyway. Standards quickly fall if there is no discipline to maintain them. I recall meeting a woman during election campaigning who was at her wit’s end trying to get her disabled son moved away from home he hated and was clearly substandard. She complained and she complained and she complained. And was completely ignored. And I note also that Andy Burnham’s experience with his dad is leading him to emphasise quality of service.
So leaving aside the problem of total budgetary funding, which is really a separate issue, let’s look at the detail. There really is no need for yet another formal report from Baroness Casey. We can do it here and now. The market/users fall into three categories:
- Home owners: Easy. They can use equity release, perhaps with the assistance of a government guarantee at minimal cost to the taxpayer,
- Tenants who want in-house care either full time or from visiting carers,
- Tenants and homeless who want or need residential care homes.
The solution for tenants and the homeless:
1. Scrap outsourcing. Instead provide users with direct means-tested access to a multi-provider market and let competition improve standards and availability by providing everyone who wants one with a National Credit Card which the taxman will partially pay off each month after assessing annually what percentage the user can afford. Any failure by the user to pay off their share can be added with interest to their PAYE code for the following year or deducted from their benefits. It is the purchase decision which drives quality, availability and value for money simultaneously in an open competitive market. No need for copious extra bureaucracy or regulation, let alone white-lists of approved suppliers which only increase costs and limit choice. If a user is happy to hire a cheaper less qualified or experienced carer and rely on online feedback, that’s between the two of them, and a regulator (see below) can just check the accuracy of information provided on online specialist marketplaces. Competition will then do the job. Users, perhaps with the help of trusted advisors, family or social workers, can then choose or switch providers when necessary, and means-testing minimises the cost to the taxpayer.
2. Introduce a standard industry-wide turnover-based subsidy for providers together with a profit cap. It is important that providers make sufficient income to cover the cost of the higher standards we expect, whether they be care homes or in-house carer agencies. This becomes especially critical as wages rise as we reduce immigration. There are of course thousands of unemployed British people who, with the right encouragement, training and supervision, could provide the services required. That training is best provided as apprenticeships and in-house courses, including post-qualification, by employers as they know exactly what they need; not by general government training schemes.
The levels of subsidy and profit cap will depend on how many providers are entering and leaving the market each year, and a regulator will be required to review and reset these as necessary to ensure sufficient high-quality provision and competition becomes available. The subsidy may vary by region, and the profit cap clawback by HMRC would be limited to the amount of subsidy received. It is important that the subsidy is turnover-based as a cost-based subsidy is likely just to disappear down through the bottom line without maximising quality output at a competitive price.
And that’s it. Now we just have to do the number crunching and find the money!
John Poynton 