The need to establish a National Care Service for Wales

Eluned Morgan explores the potential to better support the care sector in Wales.

We all want to see older people get the best possible care. However, here in Wales we have a social care time-bomb. Before it goes off it is absolutely critical that we have an honest, challenging, conversation right now about the future of care in Wales and how we are going to pay for it. Otherwise we risk facing a social crisis, the likes of which we have not seen in this country since the days of the workhouse. This is a challenge for us all: the Welsh Assembly, the Welsh Government, the people of Wales.

We need to start a discussion on the establishment of a National Care Service for Wales – a service that will in time be as loved and respected as our National Health Service, but a service that will be integral to the health service and work hand in hand with it. We need an overarching framework where people will know what to expect in terms of care in their old age and will receive a quality of service which is consistent across Wales.

It is essential that we work cross party and cross departmentally, and that we develop a consensus between generations. We need to reflect on a new funding model, which develops a fair balance between the state and the individual. We need to rethink our building policies, which could promote economic development in our communities, but most of all we need to develop a new and deep respect for the people who work in this essential service and give them the training and financial support that they need and deserve.   

Population changes

When the NHS was set up by the Labour Government in 1948, it was understood that life expectancy for men was 66, and for women, 71 years of age. Some of those poor men retired from work at 65 and were lucky if they lived for a year! Children born today can expect to live until they are a hundred. Health and care services are struggling to keep up with this demographic shift, and the State is struggling to pay for it.

Report after report has noted that something needs to be done, the amber lights have been flashing for a long time, but they are about to turn red. We, as Welsh politicians, have the possibility to steal a march on the UK Government which continues to duck the issue and to come up with our own solution to a problem which is not going away.  

We cannot deny the evidence of recent statistics, which warn us that the current system is unsustainable. In August alone, over 455 patients were recorded as experiencing delayed care transfers: that’s a lot of blocked beds!
Population forecasts for Wales predict a dramatic increase in the number of people over the age of 85 in the next 25 years. By 2037, this age group is set to soar to over 180,000, that’s the equivalent to the whole of the population of Carmarthenshire. These statistics are our families, our friends, and as a civilised society we have a responsibility to care for them.  

The costs of care

£296m was spent on looking after the elderly in Wales in 2013 – by the time I am 85 we will need to be spending almost a billion. That’s almost 7% of the entire Welsh budget. That money will have to be cut from elsewhere unless something changes.

Many people are unaware that there are limits to the State’s support of care costs. Should an individual’s savings fall below the £50,000 threshold in Wales, the State has an obligation to support care costs. However, those with capital exceeding this rate, will be expected to contribute in part, or wholly towards the cost of their care. It’s a complex system and it is perceived by many to be unfair.

Neither is care cheap. Across Wales, the weekly cost typically varies between £450-500 for residential care and £500-600 for nursing. But compare that to the cost of staying in a budget hotel for 7 nights. Add on food costs, laundry costs to your hotel bill, and then add on what you’d expect to pay staff for assistance with dressing, using the toilet. It’s pretty easy to see how the costs of care mount up.

The average time a person spends in a care home is over two and a half years, incurring costs of over £75,000. This far exceeds the average pension pot and the £35,000 lifetime contribution cap proposed by the Dilnot report, prior to State intervention. Women are particularly hard hit as they are more than twice as likely to need long term care, and are more than twice as likely to retire without their own pension pot.

Thanks to the Welsh Labour Government’s introduction of a cap on care costs at £60 a week, domiciliary care in Wales is more affordable, allowing more people to remain in their own home for longer. In addition to this, we have increased the capital people can keep to £50,000 before they are required to contribute to the cost of their care; but with these projected demographic changes, some seriously hard questions have to be faced.

Our rapidly ageing population means increasingly large numbers of older people are being supported by a smaller working population. None of us know whether we will be one of those needing care, so now is the time for us to consider whether it is time to pool the risk collectively as a society. It is probably also worth asking whether people should cover their general living costs such as food and accommodation in residential care, and separate that out from the actual cost of care.  

There is an economic impact to not acting. Not only for the elderly, but also for those with ageing parents. If people are required to leave their jobs to assume care responsibilities, then that impacts on our economy and tax system.  With the number of self-employed people on the increase, they too will be affected by caring demands.

Understanding the level of demand for future care services, and the associated costs, is paramount in how we plan for an efficient as well as equitable social care system. Given the current pressures on the NHS, we must strive wherever possible to move away from high-cost, reactive and bed-based care, to care that is preventative and proactive, which focuses as much on wellness as on responding to illness. It makes absolute sense to move where possible away from bed-based care and the Wellbeing Act implemented by the Assembly should work towards this.

Breaking down the boundaries between health and care

Finally we need to break down the artificial barriers between health and care. At the moment arguments over who pays and how to pay are clogging up the system and causing delayed transfers of care. The intermediate care fund is a step in the right direction, but heads need to be knocked together in Local Government and in the Welsh Government to smooth out the system and to save money. Local Government and the Welsh Government need to talk! £60m in a budget of approximately £7billion for health is but a drop in the ocean. We need to ask how far we should and could go to integrate health and social care – perhaps to even think the unthinkable and to merge both funds.  A hospital bed is far more expensive than a bed in a care home! Ultimately, however, it is all public money and the public don’t worry which pot it is coming from.

We cannot duck this issue and we cannot wait for England. The Labour Party rightly emphasised in its manifesto that the care sector should be a sector of strategic national importance, and I was delighted to see that this was underlined again last week in the Welsh Government’s Taking Wales Forward programme. It is our responsibility as elected representatives to bring about change on this extremely sensitive issue. This problem will not go away, we must act now and we must establish the National Care Service for Wales.

8 thoughts on “The need to establish a National Care Service for Wales

  1. Diolch Eluned. Roeddwn i’n dechrau meddwl na fu’swn i byth yn clywed y dadleuon yma oddi wrth aelod o’r llywodraeth. Mae’n adleisio yr hyn oedd gen i i’w ddweud mewn erthygl i’r IWA union flwyddyn yn ôl. Rych chi’n sôn am hen bobl yn gyffredinol. Wel, mae’r 50000 yng Nghymru sy â dementia â mwy o angen fyth am newid radical i’w gofal.
    Thank you Eluned. I was beginning to believe that I would never hear these words from a member of our government. They echo my words in an article written for the IWA exactly a year ago. My focus was on Dementia and the 50000 in Wales who live with the disease would argue that we need a radical change – I call it a revolution – in dementia care. I agree that doing away with the artificial division between health and social care is paramount. Care is care.

  2. This is a good analysis of the problem, although nothing new. But what are we going to DO about it? We all know that the system needs more money. But none of the politicians so far are saying where it is to come from -I put out a challenge at a Question Time event on Tuesday – with no response. There are several possibilities – general taxation, hypothecated taxation, social insurance, private insurance and others. All are painful but as Eluned says, we have to face up to the challenge and DO it. Way back in 1999 I was a member of the Royal Commission on Long Term Care which explored all the possibilities and concluded that general taxation, as per the NHS, was the best. No-one (including Dilnott) has come up with a better solution. The way that the current (Westminster) government has chickened-out by repeatedly deferring a decision is disgraceful.. And Wales is hiding behind and using England as an excuse which is just as disgraceful. Why don’t we learn from other countries? I favour the Japanese system which is a compulsory hypothecated social insurance system which is in addition to the normal work-based national insurance system – the trick is that it doesn’t begin to be levied until age 50 – when suddenly it becomes relevant to people because they are beginning to think about caring for their parents and for themselves and are past the other priorities of children and housing which are the main priorities of the younger generation.

  3. I agree entirely with the analysis of the problem but as to the solution I have some doubts. A single health and social care system seems entirely logical and reasonable; which is why it has been advocated for at least 50yrs. So why, in all that time hasnt it been adopted? Complexity, up from costs and affordability are some of the reasons. Our (UK) model NHS is already monolithic and as an employer often compared to the Chinese army or Indian railways in scale. A single care agency is of course even larger and even more difficult to manage. In Wales the Minister responsible would control the vast bulk of government expenditure. However competent he or she might be that is quite a task and what structures would we need to ensure accountability.
    However maybe it would all work out well but not in the short term. There would be considerable up front costs and disruption of existing services.
    How affordable is this? The NHS is already underfunded. It often does not perform as well as services across the channel but then again it gets less money. Either we ask the service to do less or we find a way of bringing in more money and getting people to vote for it. Combining two underfunded services doesn’t solve either problem.

  4. I often dip in here to read what’s on people’s minds and this article is another finger pointing to the sink hole opening in front of us. I am recently retired though active and in no way see myself as old. However I have no idea what will happen to my health, we don’t get a choice however well we look after ourselves. Health and social care go together and add to that housing, transport, friends and activities. Loneliness and inactivity increase ill health and isolation and the debate needs to be about all of these things. At best it seems to be about hospital beds or hospital at home ignoring the other needs of human beings. What we have now is scary for all of us however young and well we are at the moment. We are all going to get old and we will be reaping the rewards or otherwise of government policy. New thinking is needed, and looking up and across the usual silos would be a start. Why is government parcelled up into health, social care education etc.? Join up! Think Deventer in Holland an example of new thinking. Bringing generations together and solving accommodation problems for students at the same time. Interesting.

  5. The points raised by Eluned (and especially by Beti George and Emcee) connect strongly with ideas raised in the IWA’s first Senedd Paper, A Real Citizen Service for Wales, published in January 2014. I argued the case there, for a programme, open to 18-25 year-olds in Wales, who would give 9-12 months’ paid community service. It would be open to young unemployed people, gap year students, new graduates and others – a genuinely comprehensive initiative, which would involve a significant cohort of young adults in public service early in their working lives.
    The paper assumed EU match-funding but would now need to claim equivalent, replacement funding from Westminster!
    Echoing Emcee, it would not see young people as a “problem”, but as a valuable resource in helping to address the chronic challenges our ageing society. It derives a lot of lessons from successful community service programmes in countries as diverse as Germany and Ghana.
    I’m still trying – with ongoing IWA support – to push the idea forward.

  6. In reply to Andy, that seems an interesting idea, there are probably others out there too if we look beyond the boundaries.

  7. Diolch am eich cymorth Eluned. ‘Social care’ does not only help older people but there is a huge and growing need for adults with a learning disability and for mental health. The size of the services (most of which are provided by the voluntary and private sectors) is truly mind boggling. There are some very interesting questions such as whether a means test continues (a relic of the Poor Law), whether services are provided by councils or as at present, the welfare of the poorly paid people who work in the sector, their training and support and how carers are supported when often the carers are nearly as needy as the primary user. The degree of exposure of residential services to market risk is also a significant factor, some good English councils (eg Hampshire) have recognised this and retained and developed significant in house provision to protect their services. Apart from Learning Disability with the All Wales Strategy we have not been at the cutting edge of innovation in this sector and this could be an opportunity to do things differently.

    The provision of quality local training (akin to the Assistant Nurse Practitioner in England) would give many communities significant job opportunities and provide a coherent structure for training in this area of work.

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