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The report from Disability Law Service (DLS) sets out the social injustices that result from charging disabled people for their support to remain at home. It substantiates powerfully the case for abolition of charges for non-residential care following the lead of Hammersmith and Fulham (H&F) who did so in 2015.
The following sets out the likely reasons why no other council has followed Hammersmith and Fulham’s lead and none will. But it also sets out why adjusting the campaign objective to abolishing charges for working age people only would be morally defensible, politically feasible and eminently winnable.
Budgeting for abolition of charging
H&F’s management set out within the DLS paper how the abolition of charging was made possible through ‘effective financial budgeting’.
They planned on the basis that the only cost would be loss of income from charges. This amounted to just £324K. This is less than 1% of the gross spend of £42M at that time. This was easily achieved through cuts to ‘administrative and PR costs’.
The Council did not plan for, any increase in demand from people currently self funding their own care coming into the system.
On the face of it, this appears incredulous. The means test is far from generous. The growth of both wealth and incomes amongst the older population in recent times is known to have excluded large numbers of older people from local authority funded support. Why would these people not migrate to a free service at the point it becomes available?
The uniqueness of Hammersmith and Fulham’s situation
There may well have been some justification of H&Fs decision. It actually has a long history predating 2015 of being the only council in England to make home care free. A recent letter from the wife of the erstwhile Leader of Hammersmith and Fulham sets that history out. The Council under Labour control had abolished charges in the early 1990’s. Tories re-introduced charges in 2008 having taken control of the Council.
Whilst the Tory decision would be plainly unwelcome to people in the system with the means to pay, those people would not have had any reason to move into the self funded sector. They would have been no better off financially, quite possibly worse off, and would have lost the protection and support of the Council acting as the commissioner of their service.
H&F’s assessment in 2015 that they did not need to budget for any increase in demand may have been justified, at least to some extent. The migration from the self funding to the publicly funded sector would already have happened.
The current situation
This would have meant that the 2015 decision could disregard the scale of migration. Up to date figures tell the tale.
In 2022/23, Hammersmith and Fulham supported by far the largest number of older people in the community relative to the size of their population than any other council.
Nationally, the 330,450 older people supported in the community amongst the population over the age of 65 of 10.5M represents 31.3 service users per 1,000 population. Hammersmith and Fulham’s 1,875 older service users amongst its 19,644 population over the age of 65 represents 96.4 per 1,000 population, over three fold.
The appended chart allows a more precise comparison. The number of older service users supported in the community by their councils varies with deprivation. Charging means the more affluent communities exclude a higher percentage of people. Deprivation is measured by the Index of Multiple Deprivation (IMD). The scale is from 5.8 (Wokingham as the most affluent) to 45 (Blackpool the most deprived). Hammersmith and Fulham, at 22.3 is just above the average. A council with an IMD of 22.3 would be expected to have 36.9 service users per 1,000 population following national norms. An older population of 19,644 means there would be 720 service users.
H&F therefore support 1,155 more older service users in the community than would be expected if they performed to the national norms. That is two and a half times as many people.
Paying for the higher demand – robbing Peter to pay Paul
In order to maintain levels of service to individuals, H&F would need to have a commensurately larger budget. But it doesn’t.
The following was the situation in 2022/23.
Older people. In 2022/23, the Council spent £1,384 (adjusted for regional price differences) per 1,000 population over 65 on older people in both community and residential settings. This is a healthy 35% more than the national average of £1,026. However, it is still a significantly short of the much greater number of service users than nationally. Consequently, the average spend per older person, at £12.3K was 30% less than the national average of £18.3K
Working age people. The shortfall impacted on working age people. H&F spent £198 per 1,000 working age population. This is 29% below the national average of £278. This left the Council able to support 16% fewer working age service users in the community and spent on average 14% less on supporting them than the national averages.
H&F’s managers will say these very low levels of provision were not budget driven. They will say people are getting the right level of support as they result from what they call ‘outcome focussed and person centred’ assessments and from effective prevention work.
There are, however, two reasons to make the view not credible;
All councils say their assessments are outcome focussed and person centred’ and have a preventive approach. H&F offer no reason why they should have been so much more effective than all other councils
H&F’s service users will almost certainly disagree with the Council. The annual survey of service users provides a comparative guide to the service user experience. They show H&F as one of the worst of all councils in England;
second lowest in the country for quality of life
fifth lowest for having control over one’s life
twelfth lowest for overall satisfaction with services
fifth lowest of having as much social contact as they would like
How eligibility works in reality
This lowering of levels of support would not have required a Council decision. It will have happened covertly and spontaneously. Councils exist to meet eligible needs and eligible needs only. The Campaign for Real Care’s dossier shortly to be published – Social Care Exposed - will show how ‘eligibility’ is calibrated to ensure spend matches whatever the local budget happens to be relative to local demand.
The eligibility process has enabled H&F to rob Peter to pay Paul to fund the abolition of charging.
A winnable campaign
The potential impact on demand almost certainly accounts for why no other council has followed H&F’s lead to abolish charges. There are also moral arguments against doing so. Without the commensurate increase in budget required to fund the higher levels of demand, all suffer significantly reduced levels of support to fund it.
However, a campaign objective aimed to abolish non-residential charges for working age people only at this point in time would be both politically feasible and morally defensible.
The evidence from H&F confirms that there is not an equivalent market of working age people self funding their own care. On the contrary, H&F actually serves fewer working age people per head of population than the average and fewer than would be predicted for a council with an IMD of 22.3. The abolition of charges has not led to an increase in demand from working age as it has for older people.
The financial implications of abolishing charges for working age people only would therefore be restricted merely to loss of income. A Freedom of Information request from 6 councils chosen at random showed that income from charges for non-residential care for working age people in 20223/23 amounted to 1.6% of gross spend. This is a manageable amount for councils to find.
When this amount of money is set against the enormity of the financial, emotional and life style gains for individual service users as set out in the Disability Law Service report, the case becomes morally compelling.
Recent social trends show that working age people suffer disproportionately from charging. This renders the current system as discriminatory against working age people, abolishing charges for working age people would amount to positive action to counter the discrimination.
It would not, however, address the discrimination against older people whose means would take them just above the threshold and who, through having to pay for their own social care, are unable to afford a decent standard of life. This is one reason why the abolition of charging for all must be the long term objective.
Abolishing charges only for working age people would create tensions;
People would have to start paying on reaching retirement age
Person A with similar needs to person B may have to pay due to age while person B does not.
However, there are two reasons why these tensions should not prevail. Firstly why should all suffer when some need not? Secondly, abolishing charges for one group will set a precedent that will establish that charging is a moral wrong that needs to be put right fully in the longer-term
Older people whose assets are under the threshold for charging would, of course, continue to receive free care.
Abolishing charges for working age people only at this stage is a campaign objective shared with the Care and Support Alliance.
Summary
The Campaign for Real Care believes social care should be funded on the same universal basis as the NHS. However, there seems little prospect of that happening in the foreseeable future. The priority at this stage is to find an approach that improves the situation through a campaign that is winnable, however imperfect, but which sets social care on the right path. There may be other approaches that are equally winnable, but we believe this option offers a good way to model universalism and level the playing field for working age people in the short term.
For the political will to be found there will require a major change in the public narrative. Currently rooted in a deeply negative view of social care, it needs to become a positive narrative rooted in the wellbeing of older and disabled people. The Campaign believes that will come once the potential of the Care Act to be a Charter for the Right to Wellbeing has been realised.
The DLS report says councils should budget for ‘likely extra demand’ from abolishing charges. H&F did not do so. The alleviation of one social injustice has been secured at the expense of creating another.
Abolishing charges for non-residential care for working age people only would be both financially viable and politically feasible. It would also be unequivocally morally sound.
The horizontal axis is the average Index of Multiple Deprivation for each council
The vertical axis is the number of older service users supported at home per 1,000 population over 65 years
Each dot represents each of the councils at the point their number of service users and their IMD score meet
The trend line shows that as deprivation increases so does the number of service users.
Hammersmith and Fulham is the dot at the top of the chart, in red
The equation on the chart allows a calculation of how many service users a council with a particular IMD score will have if they follow the national average.
Hammersmith and Fulham’s IMD score is 22.27. If they followed the national average, they would have had 36.9 service users, not 96.4
Hammersmith and Fulham had 6.6 services users per 1,000 population
If it followed the national average, it would have served 7.4