#dementiatax

I never expected to be pleasantly surprised by the Conservative Party Manifesto when it was published but I was surprised at quite how bad it is. Prior to the publication of their manifesto, they had trailed that they would be addressed the long term crisis in social care funding so I was mildly interested and expected another version of the Dilnot proposals.

What we have now

Currently the threshold above which one is liable to pay for social care is £23, 250. If you are moving into residential care, your property is included in this — unless there is someone living in the property who is either over 60 or in need of support themselves (for example, a younger person with disabilities) in which case it is disregarded. The value taken from your property may be taken through a ‘deferred payment’ to the local authority so that when the house is sold — which can be after your death, the money owed will go back to the local authority.

If you are having domiliciary care, that is, care in your home, the threshold is also £23, 250 but the value of your property is entirely disregarded, as you are living in it. When your assets (not including your property) dip below £23, 250, the local authority pick up the costs.

This is a far from ideal system which needs to change and has needed to change for a long time.

Dilnot

It’s useful having a recap on the report from the Dilnot Commission. The Commission was established in 2010, after the coalition government was formed and it reported in 2011 as a cross-party approach to funding care. While the threshold which one paid for care services, whether at home or in residential settings was proposed to be raised to £100, ooo, there was also a proposed cap of between £25,000 and £50, 000 (recommended £35,000) above which you would no longer be personally responsible for payments.

I can’t say I personally welcomed Dilnot wholesale. The idea was that risk was not entirely to rest on those who needed social care but that there was an element of pooled risk. Hold onto that concept because I’m coming back to it later.

Tory Manifesto Proposals 2017

Unlike the Manifesto in 2015, when the outcome was less obvious and the government backed a form of the Dilnot proposals (although they raised the cap level), in 2017, the Tories have proposed the raising of the thresholds to £100,000 including the value of the property for those needing residential care as well as domiciliary care. This is under their heading of “A long term plan for elderly care”. “Elderly care” — yes, seriously. That language is not exactly 2017. We haven’t referred to older people as “elderly” for a long time for a reason but that’s probably the least of my problems with it. For a start, there is no acknowledgement in the slightest that social care is delivered to adults over 18. Yes, we have an ageing population but by refusing to acknowledge that adult social care touches adults of all ages, the Conservative Party are evidencing a lack of understanding of the issues at home.

The argument they make is an odd one too, given they reduced inheritance taxes last year, is that ‘why should a healthy 25 year old who can’t afford a property pay the social care costs of a 75 year old with a house valued at £400,000'. On the Marr Show today, some identikit Tory minster said this was a policy which was aimed at leveling generational inequalities. A strange comment from a government minister who has showed little interest in generational inequalities to date.

Exploring the gaps in the Tory policy

So I might have got ahead of myself here but it’s hard to know where to start with this policy which feels very ‘back of the envelope’. I’ll start with some of the ‘defences’ of it I’ve heard on the TV and radio since the manifesto was published.

The first is that there is a great misunderstanding of adult social care and what it delivers. This is why it has become known as the ‘dementia tax’. The blurred line between health care (free) and social care (means-tested) is the key issue which has not only not been addressed but has been blown into the spotlight in this proposal. People have made comparisons with cancer care but it’s not really about that. Social care is about ‘life and death’ as much as health care. By supporting someone with dementia, or chronic arthritis or increased physical frailty at home — you are promoting rights, preference and potentially prevention of greater deterioration in health (and higher public costs if we want to be blunt but also higher human costs if we want to be fluffy social workers). Saying that Mrs Smith must pay for her social care but not her health care we are making an arbitrary distinction. Yes, people with diagnoses of dementia would more likely to be funded by social care pathways is a part of it but it’s not the only condition or need. If the Tory argument is “It’s unfair healthy 25 year old pays for care that a 75 year old with dementia at home gets” then we can extrapolate exactly the same argument for healthcare.

Why should a healthy 40 year old pay for a 20 year old born with disabilities? See — it’s a pretty revolting argument if you extrapolate it. We need to create the society we want to have.

Secondly, there’s a big hole that I haven’t seen addressed much in the Tory idea — which they claim is just evening out the ‘gap’ between the thresholds for residential care (where home is taken into account) and domiciliary care (where it isn’t) is that the numbers of those who receive domiciliary care is much greater than those who are admitted to residential and nursing care. This number will continue to increase as there is a preference (rightly) of providing care in people’s own homes. This means so many more people will be affected by this. And I’m not convinced people — in general — have an idea of how much social care can cost over a lifetime. This is what Dilnot’s cap was intended to solve. Care costs — at home as well as in residential settings, can easily build up to hundreds of thousands of pounds over the years. Yes, I meant that. It can easily munch through the price of a house.

A practical implementation

Having worked in older people’s services for many years, I can see so many difficulties in this proposal. There’s little detail in the manifesto, of course, but what will exist to stop people dodging these charges, if they have access to financial advice by transferring properties around the families and into various trust funds which those who are able to, will do.

One of the roles I had, among many, was explaining to people, sometimes for the first time that the services we had assessed them as needing would need to be paid for. A surprising number of people assume social care is free — like health care. Until you come to them with a bill. Older people I worked with, some of them refused to have the financial assessment at all, saying they didn’t want the local authority to know the details of their finances. I can understand that. But it did mean we had to charge them at the full rates even if we knew they wouldn’t have met that threshold. See, it’s not just about how much money is in your account, it’s about how much is in joint accounts and spousal arrangements. Not everyone wants to share that.

The other aspect is that we could go in and assess someone, but if they were unwilling to pay the amount determined, we would not be able to provide ANY service. This meant that people would go without desperately needed care because they didn’t want to disadvantage their children/grandchildren. I expect to see a lot more of this.

The other area, which has changed to some extent with the 2014 Care Act but not, I suspect, enough — is that once someone was assessed as being ‘self funding’ some of the responsibilities of the local authority were divested to that individual to arrange and sort their own care. Yes, they have a right to advice but that can be very low level. It isn’t the local authority’s money so there isn’t the same responsibility. This may leave a lot of people in an increasing gap.

A solution

Both the Labour and Liberal Democrat manifestos recommend a Dilnot-style cap. Personally, I favoured the much-derided ‘Death Tax’ which provided a more accessible universal right to social care. Social care needs to be regarded as being as necessary as health care. This plan will see more people risking their health and their lives to protect their children. Because that’s what people do. My worry, and I hope I’m not being overdramatic, is also that people will be more likely to want to die earlier because of the potential costs to their families, rather than because of the changes in their qualities of life.

While an identikit Tory politician on the Marr Show this morning said “£100,000” is quite a lot — and it is — if you think about how much that might get you if you want a property in the south-east, you can see the lack of heart in that comment.

I am completely comfortable with the idea that people with more should pay more. That doesn’t worry me in the slightest which is why I favour the money being taken through an inheritance tax-like system. But this system pushes the cost of the misfortune of X diagnosis or ill-health rather than Y onto individuals rather than pooling the risk among the population or those who can best carry the burden, namely through the use of progressive taxation.