Time to end unfair and inconsistent charging system

Chris Common, acting assistant director for policy development at Law Centre (NI), argues for the introduction of free personal care in Northern Ireland.

Long-term care currently is at the top of the political agenda in Northern Ireland because it remains a reality for thousands of local older people and a source of anxiety for many more but also because of the widely held belief that the current system is unjust and needs addressed.

There has been a growing demand for personal care to be provided free rather than the current system which requires a complex financial assessment to be undertaken and charges levied for services provided where deemed appropriate.

Long-term care, specifically personal care, encompasses help with those tasks that a person would normally do for her/himself such as dressing, eating, washing and bathing, toileting, getting in and out of bed, moving around the house and keeping safe.{footnote}Report of Free Personal Care in Northern Ireland July 2002.{/footnote}

Free personal care is essentially a mechanism for removing charges for personal care services for people aged 65 and over who are assessed as needing them and who would have previously had to pay for them.{footnote}Evaluation of the Operation and Impact of Free Personal Care prepared for Scottish Executive, 2007.{/footnote}

Issues

In Northern Ireland there are a total of 270,592 people (95,407 males and 175,185 females) of pensionable age out of a population of 1,702, 628. The proportion of people aged 65 is projected to rise from 13.3 % in 2001 to 24.8 % by 2041. The number of very elderly people (85+) is, at the last count, 23,560.{footnote}NIRSA, Mid-year estimates, 2003.{/footnote}

Whilst most are fit and active and make a substantial contribution to life in Northern Ireland, it is an unfortunate fact that many older people will suffer from serious illnesses. Many of those illnesses will not be solved by acute care but will be chronic in nature, requiring long-term care to be provided. The extent of the need to provide long-term care is an important matter to consider. Certain predictions can be made (with caution), for example, it has been found that around one in two women and one in three men who have turned 65 will require intensive long-term care in the run up to old age.{footnote}Glennerster 1996 (Paying for Long-term care for older people in the UK: Personal Social Services Research Unit).{/footnote}

The difficulty that arises for older people who have suffered illness is that if an individual has been ill in hospital and is discharged back into the community, either to her/his home or to a care home, the bulk of her/his needs are no longer for ‘health care’ but for ‘social care’. The NHS does not cover social care, so the person has to pay for it.

Not only does this approach fail to command public support because of the expectation that ‘care’ would be free and provided by the state, but there are regional variations in implementing policies such as eligibility for services and charging levels.

As stated in the Personal Social Services research unit paper Paying for long-term care for older people in the UK, ‘The NHS embodies a definition of fairness, which provides health care on the basis of health needs rather than the ability (or lack of ability) to pay. In contrast, access to publicly funded social care for older people takes account of both care needs and ability to pay. These differences led to a number of inequities including diagnostic inequities… funding of residential care… variations in the eligibility criteria for fully funded NHS care… and whether the specific form of the means test resulted in a fair distribution of public expenditure on social care for older people.’

The implementation of the policy for charging within care homes has provoked a sense of betrayal of long held values and beliefs in the state supporting all of its citizens.

A recent report by the Joseph Roundtree Foundation noted: ‘Means testing effectively impoverishes people before they can get state aid other than nursing care. Much attention has focused on the need to run down capital from selling one’s home before receiving assistance. But in addition, for those qualifying, care is not free but requires the surrender of almost all income leaving a meagre living allowance of just £20.45 a week if they are being supported to live in a care home’.{footnote}Joseph Rowntree Foundation Paying for long-term care: Moving Forward. April 2006 ref 0186.{/footnote}

This issue is felt deeply by older people who consider that they have spent a life-time working and paying national insurance contributions into a system that is perceived to be letting them down when they most need its support. Families can be resentful at the apparent injustice heaped upon their parents at a time where there is often a crisis because of deteriorating health. Instead of the expected caring support from statutory bodies, an assessment of need is rapidly followed by an assessment of financial resources.

This is compounded by the fact that the majority of residential and nursing homes in Northern Ireland charge a top-up fee for residential care which can be as much as £100 per week. This is over and above the cost met by the trust. When the person in need of care is admitted, a family member is required to sign a contract to confirm he or she will meet the top-up payment, this often at a time of stress, and without full knowledge of the ramifications.{footnote}Rights in Community Care briefing, December 2006.{/footnote}

Not only is the system unfair and inconsistent, but also users of services often find it hard to understand what appears to them an incoherent and complex funding structure.

Actions

There has been considerable debate for some time about how long-term care is to be funded.

In December 1997, the Labour government appointed a Royal Commission on Long-term Care for the Elderly to examine options for a sustainable funding system and to recommend how the cost of care should be apportioned between public funds and individuals.

The report of the Commission, With respect to old age,{footnote}Royal Commission on Long Term Care for the Elderly: Final Report (March 1999): With Respect to Old Age: LongTerm Care-Rights and Responsibilities.{/footnote} was presented to the government in March 1999. The report made the distinction between the costs of personal care and living and housing costs and anticipated the need to establish a national body to monitor and benchmark care standards and represent consumer interests.

The Commission recommended that: ‘The cost of long-term care should be split between living costs, housing costs and personal care. Personal care should be made available after assessment, according to need, and paid for from general taxation; the rest should be subject to co-payment according to means.’

Scotland has been the only UK jurisdiction to fully act on the recommendations of the Commission. A payment is now made towards personal care both in residential and in nursing homes and charges for care in people’s own homes have been abolished.

There remain significant differences in terms of publicly funded social care between Northern Ireland and Britain. For example, non-residential personal social services in Northern Ireland have attracted a relatively low level of charge and in many cases are provided for free. In England and Wales, most local authorities levy charges for non-residential services, including domiciliary care, and the scale of charging is much greater. Another difference is that there is provision for continuing NHS care in England and Wales. This means that some people are cared for outside of hospital, for example in a care home, but all the costs are paid by the health authority. In Northern Ireland, people with similar health care needs would be considered to be receiving social care and would be charged for the service.

Where to now?

The Evaluation of the Operation and Impact of Free Personal Care prepared for the Scottish Executive{footnote}Evaluation of the Operation and Impact of Free Personal Care. Paolo Vestri. Hexagon Research and Consulting, 2007.{/footnote} stated that ‘The primary aim of free personal care is to remove discrimination against older people who have chronic or degenerative illnesses and need personal care by bringing their care into line with medical and nursing care in the NHS, where the principle of free care based on need is almost universally applied and accepted.’ Should society be content to avoid the immediate introduction of free personal care and thus risk being described as discriminatory in its dealings with its older generation?

The Northern Ireland Assembly recently debated the introduction of free personal care. Health Minister Michael McGimpsey stated: ‘There is an injustice in our society which sees the frailest members of our society being forced to give up their family home to pay for care in a nursing home. These people are being asked to contribute towards their care by losing their most valuable and hard earned asset - their home. (…) It is an issue which was raised by the Assembly in 2001 and resulted in a report which estimated the cost of implementation to be over £40 million.

I have asked for an urgent and comprehensive update on the 2002 report which will consider the experiences of Scotland and Wales and identify the cost of any other potential options.’ We await the result of the review, which is due to be published shortly, with interest.