Initial thoughts on the Dilnot Report on Funding of Care and Support

Scheduling and exhaustion meant I didn’t have time to look at the Dilnot proposals in detail yesterday so this morning I have fired up my browser and am going to make a few initial comments on the baseline main recommendations and hopefully over the next few days can look at some of the details.

The Dilnot Report on Funding of Care and Support runs at 82 pages.  It attempts to forge a solution for the currently antiquated and inequitable system of care funding that is currently in place. Much talk has been made of the current threshold of £23,250 of assets, at which people currently become responsible for paying for their own care services but little made of the current discounting of homes in certain circumstances and the ability to raise a charge on a property to postpone payment of costs for care services. Nevertheless, this threshold was deemed as being too low. People who own houses like to keep houses for children. People don’t like those who ‘haven’t worked as hard’ or ‘saved as much’ getting something for free.

The system is broken though, don’t get me wrong, I just think the focus of the discussion has been too much around middle class fears of actually paying for something they believe should be free. Now, I’ve got that off my chest, back to the report.

The main recommendations are

– to cap lifetime costs of care between £25,000 and £100,000 – with a suggested threshold (which is used throughout the report for ease) of £35,000

– means-tested assistance will be extended to those who have between £23,250 and £100,000 of assets.

– Those who ‘enter adulthood’ with support needs will not be means-tested and care will be provided free.

-Universal disability benefits will continue but may be some differences in names regarding Attendance Allowance. (erm.. DLA?).

– There will be a cap on so-called ‘hotel costs’ in residential care between £7,000-£10,000

-There should be a national, portable eligibility framework which is more transparent.

– A government awareness campaign about planning ahead and preparing for potential age-related disabilities. And their costs.

– There should be a new information and advice strategy to help people through the confusing forest of knowledge.

– Better carers support and information.

– More health and social care integration

Of course, these recommendation run alongside the Law Commission’s report for changes in adult social care law. Together they could create a much better and clearer system than we currently have.

The ‘lifetime cap’ allows for insurance policies to be generated and probably very profitable ones too for the insurance companies. Most people do not need high level social care provision but the fear generated by the media is enough to drive right minded people into the arms (those who can afford it and who have substantial assets) into the arms of the insurance companies. I’m not sure how comfortable I am with the lifetime cap on care costs. It means the more wealth someone has, the more they are protected. I understand the logic behind it in that noone chooses ill-health and disability but the more than government spends on those who do have substantial assets, the less there is for those who cannot afford it and the higher the criteria to access support rises.

I just have a few queries which may be answered in the details. If Mrs Smith has a house worth £300,000 and she lives alone with no other substantial assets – say, for example, she has savings of £10,000 – is her house sold to release the asset worth up to the cap of £35,000 – assuming she doesn’t have an insurance policy? If she chooses to live in a care home which is private, but then the money runs out, will the local authority still move her? Will she ‘top up’ the local authority fees, paying above the ‘cap’ to do so? What is she lacks capacity and has no family?  I suspect all these answers are in the report but they will be questions I will be looking for.  The system of deferred payment is mentioned and I’ll hunt around for clarification.

The cap though, seems to be there to protect middle class votes.

I do, however wholly support the increase in the level of means-testing. I think it is entirely right to continue to means test up to £100,000 and I’d even go further than that. I don’t have a problem with mixed funding, I am just not entirely comfortable with the capping.

Again, the clarity of the coverage of those who ‘enter adulthood’ with care needs is entirely right. There is a necessary distinction between working age adults with care needs and older adults with care needs but quite rightly it is wrong to have a distinction fixed at a specific age. Indeed, Dilnot proposes that those who develop long term care needs before the age of 40 should continue to have a zero cap and costs should be met fully by the state. Above the age of 40 there will be some kind of tapering of the cap up to retirement age where the full proposed £35,000 cap would be reached.

Regarding the accessibility of universal disability benefits, Dilnot clarifies that he does not propose any reform that would lead to anyone losing their disability benefits and that attendance allowance will continue. I do wonder though how this ties in with the government plans to remove 20% of DLA claimants.

There are some recommendations though to change Attendance Allowance (AA). Firstly to change the name to something more understandable and an appreciation that many who are eligible for it do not claim it. That absolutely reflects my experience.  People who reach the cap when the government takes over payment will not continue to receive Attendance Allowance (or whatever it will be called) because the government is fully paying for their care needs – which makes sense to me.  The Personal Expenses Allowance (PEA) is proposed to continue – this is the payment that is made to people whose costs are met by the government in residential care and is currently about £23 pw – there is a suggestion that it should increase but not a recommendation.

The cap on hotel costs is excellent news in my view because I saw this as a potential ‘get out’ clause for residential homes. I do want to know how some of the private homes will adapt to these new systems though and what the cap will mean for overall quality of care provision.

The idea of clearer, portable assessments is a good one and long overdue. Eligibility criteria interpretation can differ wildly and there needs to be more transparency.   The minimum threshold would be applied at the ‘substantial’ level of care so I wonder how this portability will work for those who live in areas that meet lower levels at present.  It seems that there is some kind of recommendation to do away with FACS over the longer term.

Can’t be soon enough – a new assessment framework will be developed ‘with experts’. Please please please can front-line practitioners be involved in these developments – not just people who professionally develop policies and have never needed to use assessments in their lives. This is why we end up with unusable systems. There is also a way of building self-assessments into these new models. That’s the idea anyway.

The last recommendations about building awareness and improving quality of information seem to be sound all round. Nothing to argue about there.

I am interested in the recommendations as they relate to carers. As far as I am concerned, I want more than just an assessment for carers, I want the provision of more services. Supporting carers very well both financially and with practical and flexible support is probably the one aspect which can potentially save the government more money in the longer term than anything else – but more than that, it is an issue of ethics and morality. I know that doesn’t often come into government services but it’s something I feel very strongly about.

There is more commentary about the details of Dilnot in Community Care, the Guardian has extensive coverage (including an article I wrote before the details were known).

I also recommend Arbitrary Constant for links and discussion about Dilnot.

Cameron and Multiculturalism

DAVOS/SWITZERLAND, 29JAN10 - David Cameron, Le...

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Firstly, apologies that I’m a little late to this but I wasn’t around at the weekend to comment.

Cameron made a speech on Saturday in Munich was an attempt to echo Merkel’s speech in October where

She said the so-called “multikulti” concept – where people would “live side-by-side” happily – did not work, and immigrants needed to do more to integrate – including learning German.

The full text of Cameron’s speech is on the New Statesman site.

It’s useful to actually read the text as opposed to the commentary to get the ideas behind what Cameron was trying to say. There seems to have been a lot of interpretation of what he might have meant.

This was a speech in the context of fighting terrorism (thats fairly uncontroversially  ‘a good thing’).

Cameron, for example, said

It’s important to stress that terrorism is not linked exclusively to any one religion or ethnic group.

The UK still faces threats from dissident republicans.

But with the rest of the speech he wholly refers to Islam and Muslim extremists. He isn’t really broadening the debate very much apart from that one sentence.  Yes, he makes the right noises about not equating the religion of Islam with terrorism but he does seem to relate increasing extremism to a loss of identity that may be caused by more disparate communities existing side by side.

Under the doctrine of state multiculturalism, we have encouraged different cultures to live separate lives, apart from each other and the mainstream.We have failed to provide a vision of society to which they feel they want to belong.We have even tolerated these segregated communities behaving in ways that run counter to our values.

So when a white person holds objectionable views – racism, for example – we rightly condemn them.But when equally unacceptable views or practices have come from someone who isn’t white, we’ve been too cautious, frankly even fearful, to stand up to them.The failure of some to confront the horrors of forced marriage the practice where some young girls are bullied and sometimes taken abroad to marry someone they don’t want to is a case in point.

This hands-off tolerance has only served to reinforce the sense that not enough is shared.All this leaves some young Muslims feeling rootless.And the search for something to belong to and believe in can lead them to this extremist ideology.

For sure, they don’t turn into terrorists overnight.

What we see is a process of radicalisation.

I know it’s a long quotation from his speech but I think it is the crucial argument that he is making.

He claims that it is the lack of an over-arching ‘British’ identity that has led to alienation and in turn, the radicalisation of a group of ‘young Muslims’.

I have a lot of problems with this assertion to be honest. I am a Londoner and I have lived for almost all my life in London– I have also lived in a country which is arguably more monocultural than the UK  (Italy) which immediately puts me in a different sphere of existence than David Cameron (Berkshire, Eton, Oxford).

Consensus is the way to create community rather than ostracisation.

Tackling inequity, racism and religious intolerance is a way to create community.

Making immigrants, no, scratch that, making EVERYONE feel that they have a stake in the community and the environment in which they live is the way to create community.

Targeting ‘a doctrine of state multiculturalism’ (the language is very negative for a start) and blaming that for ‘home-grown’ terrorists seems to be a facile argument designed to play into the increasingly dangerous ‘Daily Mail leader writer’ school of populism at the expense of any understanding of what might be happening or trying to analyse any of the issues below the surface.

Maybe it is the alienation in the mainstream communities that needs to be tackled.

I know it’s been commented on frequently but the fact that the English Defence League, an odious and divisive group set on castigating and demonstrating against Islam (no, it isn’t just ‘extremists’ as they claim) had a rally on the same day as Cameron’s speech led some of them to feel vindicated which is both sickening and irresponsible on the part of Cameron. Maybe he had no control over the timing but he could have explicitly condemned the EDL. He didn’t.

Thanks to Wikipedia, I was led to an article in the Guardian,  last year about the EDL – worth reading and reflecting on in the light of Mr Cameron’s speech.

A strangely relevant part jumped out at me

For Matthew Goodwin, an academic who specialises in far-right politics at Manchester University, this is a crucial difference between the EDL and previous far-right street movements.

“The reason why the EDL’s adoption of Islamophobia is particularly significant is that unlike the 1970s, when the National Front was embracing antisemitism, there are now sections of the media and the British establishment that are relatively sympathetic towards Islamophobia,” says Goodwin. “It is not difficult to look through the media and find quite hostile views towards Islam and Muslims. That is fundamentally different to the 1970s, when very few newspapers or politicians were endorsing the NF’s antisemitic message.”

“The point for your average voter is that if they see the EDL marching through their streets shouting about how the neighbourhood is about to be swamped by Muslims or how the UK is going to be Islamified by 2040, they are also receiving these cues from other sections of British society … the message of the EDL may well be legitimised if that continues.”

And this is Cameron’s message from his speech.

It seems odd that he is so happy to back faith schools in the context of his speech.

He can’t get away from the fact that he has targeted Islam specifically. The headlines will be filling in the gaps.

This was not a brave speech. It was a cowardly one that pandered to far more dangerous societal views. Far braver it would have been to take actions to improve the living environments of those who feel cut off from society through racism – open and institutional and by tackling poverty in the inner cities where a lot of immigrant communities live.

Far braver to openly confront and condemn the EDL. And the right-wing press that has created a dangerously high level of ‘us and them’ politics.

Maybe it is the attitudes of our society that creates the alienation rather than the embracing of different cultures, religions and backgrounds.

I notice that Cameron also said

So they (apologists for ‘multiculturalism) point to the poverty that so many Muslims live in and say: get rid of this injustice and the terrorism will end.

But this ignores that fact that many of those found guilty of terrorist offences in the UK have been graduates, and often middle class.

I think Cameron has completely forgotten that sometimes, ok, not in his sphere of existence, middle class people want to demonstrate and act against perceived and real injustices happening not just to themselves but to others less fortunate who have not had the same opportunities. And hard though it might be for Cameron to understand – you can actually grow up in poverty and be a graduate. The two things aren’t (yet) mutually exclusive.

When I lived in Italy in a society that very much promotes the mono-culture, there was far more explicit racism present than I have noticed in the UK. ‘Other’, ‘difference’ was not a positive.

It was not a better society.  People from other religious, cultural and ethnic groups were openly scorned. Look at the mainstreaming of the ‘Lega Nord’ if you want to see the dangers of moving away from open multiculturalism.

I doubt Cameron understands multiculturalism because he, his class, and the people around him have only gained their information and advice from ‘people like them’.

He castigates intolerance within Islam but does nothing to even mention or acknowledge the invidious nature of the march in Luton happening on the same day. He could easily have criticised it. He didn’t.

The richness that diversity brings to our cities and our country is not something that has a dark responsibility for terrorism.

Alienation of diverse groups may lead to extremism – I’m not a sociologist and haven’t read any significant research for a while – but increasing marginalisation by highlighting one religious group as responsible for ‘home-grown’ terrorism – while ignoring the issues such as faith schools – which he could easily challenge –  seems to be exacerbating the problem.

I love my city. I wrote previously about why I loved London. I love living and working around different communities that are able to live side by side, just as my ancestors, immigrants themselves, were accepted when they arrived.

This speech has just given a whole swathe of ‘middle England’ a chance to step on the EDL’s agenda.

It has to be challenged. Challenged hard and challenged frequently.

It is anti-racism, anti-discrimination, anti-oppression and equality of opportunity that will eradicate ‘home grown’ terrorism.

Not the elimination of multiculturalism.

How Fair is Britain?

Today, the Equality and Human Rights Commission publish their first Triennial Report about Equality, Human Rights and good relations.

Some aspects of the report have been published over the weekend but it is worth reconsideration and reflection.

The report is divided into eight areas – Life, Legal and Physical Security, Health, Education, Employment, Standard of Living, Care and Support and Power and Voice.

Time, as ever,  hasn’t permitted me a full brief of the details but one of the most obvious thoughts to jump out from me through my initial glances is that race is important. Of course, this comes as no surprise to me, after all, I work in a Mental Health team in Central London but anyone who feels that discrimination and oppression is somehow invented cannot escape from the figures presented.

The study itself looked at different outcomes in various categories in terms of ‘

‘Age; Gender; Disability; Ethnicity; Religion or belief; Sexual orientation; Transgender status.

Where appropriate, the Review also takes into account the impact of socio-economic background, or class.’

(nb just if I happened to be a social work student or a student of sociology/social policy – I would hold onto this report and keep it dear, it will be absolutely priceless in essays and research!).

There is masses of data present in  this report but I’m just going to pick out a few pieces which I find particularly interesting or of which I have particular experience.

In the Health section

The incidence of disability rises with age and older people (65 and over) also have a higher rate of depression than younger people. There is evidence to suggest that the health service sometimes deals with some older people in ways that they find humiliating or distressing.

This might sound obvious but it is crucial that the higher rates of depression in older adults is accounted for. Working in a specialist older adults mental  health team, when explaining to colleagues in other teams who usually assume that most of my work is with people with dementia, I often have to add ‘depression’ into the mix. This is increasingly important as the ‘Payment by Results’ and outcome measures creep into Mental Health Services. I am well overdue writing a specific post about ‘Payment by Results’ in Mental Health but each time I think about it, my heart sinks.

This higher rate of depression needs to be provided for and I fear that through various means and changes that are taking place in the services, it may be lost to teams such as ours unless it is very severe.

The second part that notes the health service deals with older people in ways they find humiliating and distressing definitely bears out to my experience. I consider it partly because no-one in the health service knows what it is like to be very old – we are, of course, working age by default. We might have elderly parents or spouses but in a way that we all might experience ill health, we can’t obviously have experienced being elderly. As long as older adults are seen as ‘the other’ ‘someone else’ that almost allows a sense of different treatment and attitudes.

Even in my team, although it pains me to say it, I’ve heard some appalling language and assumptions made just because someone is old. The increasingly elderly population and the perception that people who have no economic output are less ‘valuable’ that people who work is a modern attitude that permeates not just the Health Service but society at large.

This ‘being a burden’ is an attitude that has played out in wider scales but it is always a challenge.

On similar lines

Overall, around 1 in 5 of us report a disability or limiting long-term illness (LLTI). The available evidence suggests that people who report a disability or LLTI are as likely as average to say that the health services treats them with dignity and respect.

So who is the health service treating with ‘dignity and respect’? Or are we more critical when we are more vulnerable? I am inclined to think that the more people are ‘like us’ the more likely other people are to treat them with dignity and respect.

Is the answer training? Possibly although there is already a lot of training. Personally I think the way to improve is through having good and strong managers who take to task firmly those who step out from the line. The difficulty is that if the attitudes are coming from GPs and consultants, who reins them in? The hierarchies within the health service are immensely powerful.

In the Mental Health Section

Groups vulnerable to pressures such as poverty and victimisation show high rates of mental illness. The risk of having poor mental health scores is higher for certain ethnic groups with high poverty rates.

which doesn’t come as a great surprise. The correlation between the stresses of poverty and poor mental health are very well established but put on paper

The risk of mental health problems is nearly twice as likely for Bangladeshi men than for White men

which is a massive proportion. I wonder how many specialist provisions exist for Bangladeshis within the Mental Health system. I know this is very much related to poverty and specific areas where the community lives but it is something that absolutely needs to be addressed.

Personally, I feel that tailoring services to particular ethnic and cultural groups is valuable within mental health services although of course, this tailoring has to happen on geographic lines where the needs are greatest – however, these services cost and tend to be less than popular among those of the majority who might feel excluded. I’ll be interested to know about what effect these figures and this report might have on the commissioning of services.

In the Care and Support section

Unsurprisingly, women are more likely to provide informal care than men.

Different ethnic groups draw on different forms of care to different extents. Black children are more likely to be in formal childcare than others; Bangladeshi and Pakistani children are much less likely. Meanwhile, Bangladeshi and Pakistani
people are significantly more likely than average to provide informal paid care (more than twice as likely as White people). Some literature suggests that this may, in part, be because formal care services are not always appropriate to meet the particular needs of some ethnic minority groups.

I thought this was a crucial paragraph. Black children are more likely to be in formal childcare than others. That starts a child off with so many more challenges throughout their lives. I know it is a generally perceived fact within the childcare system and I hope it continues to be a focus for support and evaluation of options.

The last sentence there is also key. Is there a difference in availability of specific services for people with particular ethnicities.

On a personal level, although theoretically our service should provide culturally specific services, it is sometimes hard to source carers with particular linguistic skills for example. This may be a matter of access to training  from those within these particular communities and a lack of enthusiasm and active engagement by service providers. Specific services also cost more although to be fair, everywhere I’ve worked, this is something that has ‘been allowed’. The problem is not paying for the care but finding the care in the first place.

Britain’s demographic trajectory – in particular its ageing population – is creating new kinds of chronic disadvantage. Over the next decade there will be a steep increase in the demand for personal care for older people. At the same time, more people who might have cared for their parents will have dependent children. This often means a concentration of informal care provision falling on a relatively small group – the dutiful middle aged. Most carers are women although a significant number are also children.

I think this raises a massive ‘red light’ to services and a big push towards where we are heading. It’s no surprise that the ‘ageing population’ will demand more care and the issues of how that will be funded have not yet been resolved, however add to that people who might be having children later than previous generations and you do have the challenge of the dual caring role – caring for young children and elderly parents.

This will be an increasing issue not necessarily today, but in 10-15 years time when the people who are in their late 30s and early 40s have children and whose parents might need that support in their late 70s and 80s.

While the study talks of the ‘dutiful middle aged’ this will be a group of people who have grown up in a prosperous society and might not have been as well-adjusted to the nature of the caring role as their parents’ generation. Most important to note is how much of this care role may fall on children, especially as parents grow older.

We are still waiting for the outcome of the Commission on Funding for Care and Support but someone will have to pay either for care or to support carers more substantially. This is not an issue that will fade away – quite the opposite.

In the Power and Voice section

In the Westminster Parliament, despite some evidence of progress, most religious and ethnic minorities are still under-represented. However, lesbian, gay and bisexual (LGB) people, and some people from ethnic and religious minorities, are more likely to take part in other forms of political or civic activity and more likely to feel able to influence local decisions.

People with a disability or a long-term limiting illness are generally less likely than those without to say that they can influence local decisions, and a majority of polling stations at the last election presented at least one significant access barrier.

There are a few points there. The lack of representation in Westminster seems to point to a particularly privileged group of people who go into ‘career politics’. It’s interesting to contrast with local activism which is usually carried out by a different group of people. Perhaps there is a greater feeling that local decisions can actually be changed and influenced by active minority interests.

Worryingly the fact that polling stations have access issues is one that needs to be addressed immediately. I wonder if the lack of engagement with the parliamentary process from specific groups of people allows national politicians to increasingly stigmatise these groups.

people’s socio-economic background affects their sense of power and voice. Professionals are more likely to vote, more likely to hold elected office, and more likely to feel that they can influence local decisions than people from lower occupational groups.

This sense of entitlement should come as no surprise, perhaps the weakening of the union movement is changing perceptions or just the innate nature of the existence of the perception of a ‘ruling middle class’. I would hope that Citizenship classes at schools could challenge some of these assumptions but I have no idea what happens in Citizenship classes!

National engagement through local engagement seems like the obvious way to have different kinds of voices shouting at the highest levels.

The report identifies particular areas in which work and progress can be made but I think while some of the findings are not surprisingly, it is useful to see them placed in terms of data that can be analysed and measured.

Data means that the next triennial review in 2013 can be matched and progress can be matched.

The worries remain mostly about money and funding. Everything costs, including changing attitudes throughout society and creating a ‘fairer’ Britain.

I wonder how many of the challenges specified in this report will be picked up by both a government and an opposition couched in creating fairness across our society.

To me, it seems like the white, middle class earner is doing quite well out already in the ‘fairness’ stakes so more attention on the deficits of equality would actually be the way to go if we do want to create a ‘fair’ Britain.

But the rhetoric of fairness seems to be appealing specifically to the ‘haves’ – rather than the ‘have-nots’ but at least we have a baseline of what we expect a ‘fair’ government to be working towards.

Very apt timing for the report. Let’s see what the Government does about it.

Mental Health and Public Office

While pottering around on the web, I came across this story from the Camden New Journal, about Councillor Chris Basson – an elected official who suffers from bipolar disorder.

He resigned from his post earlier this week, following, according to the article

three years on the council that were wrecked by poor attendance and gossiping.

Poor attendance, fair enough, but I think we can venture a guess or two as to what the nature of the gossiping might have entailed.

His statement of resignation reads as follows

“I was diagnosed with Bipolar Affective Disorder in 1996 – more commonly known as manic depression,” he said.
“With appropriate medication, I was able to manage the condition in the run-up to the 2006 election. However, since then I suffered from a series of relapses including nervous breakdowns – which have involved hospitalisation – and I have struggled to bring the condition under control.”
He added: “I have been unable to carry out my duties in the way I wanted. I regret that I haven’t had the confidence to talk about this publicly before now in the way that others, such as Stephen Fry, have.”

Honestly, I was struck with more than a hint of sadness when I read this. It does make me realise the importance that the removal of stigma has.

How supportive do opposing politicians need to be though?

In a tense week at the Town Hall, the Lib Dems have been accused of picking the wrong candidate in the first place and then allowing Mr Basson to stay in office longer than was appropriate.
Labour councillor Jonathan Simpson: “Of course it is sad whenever somebody experiences difficulties like this but this is why you have to be careful about which candidates you chose. ”

Personally I feel the Lib Dems come out of this with more credit than the Labour councillor quoted above.

It’s interesting that while enforced hospitalisation would disqualify an MP, it would not disqualify a councillor. And the people in that ward would not remain unrepresented by one councillors absence as there are three councillors per ward and it sounds like party members may be willing to provide cover for colleagues.

However there is also a statement explaining that his health has deteriorated since his election. Perhaps the pressures of public office have taken their toll? So, the opposition parties claim, have the Liberal Democrats failed in their duty of care to this councillor by not persuading him to stand down earlier?

It’s hard to know which way to call it. It is a sadness though, for him and those associated with him. We need people who understand and experience services and situations that the people they represent do.

Similarities are drawn with another member of the same council,

It had been an open secret at the Town Hall that Mr Basson was in poor health – his attendance seemed to get worse and worse – but the issue was not pressed. To some extent, this sympathetic convention mirrored the treatment of Camden’s longest-serving Labour councillor Roy Shaw, whose health failed while he was in office.

It’s hard not to determine that the differential consideration is given to a councillor whose physical health fails but when he becomes more unwell mentally, it becomes a game for political football.

I certainly wish Basson a speedy recovery and certainly hope this does not put an end to the impact that he has on public life. Not least because it allows a much deeper exploration of prejudices.