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The good news is that no 'demographic time bomb' threatens the public purse. But the Royal Commission on Long-Term Care's proposal for free personal care, funded by direct taxation, has unsettled the government. Kaye McIntosh reports

It was all going to be so different. A royal commission is the politician's traditional way of shelving difficult decisions - such as how to fund long-term care for the growing number of elderly people in the UK.

Years pass, ministers move on, and either everyone forgets about the commission or its recommendations are a problem for someone else.

But the Royal Commission on Long-Term Care was not going to be like that. It was the first royal commission set up by the Department of Health for 20 years and was a Labour Party manifesto commitment.

Health secretary Frank Dobson asked it to report within 12 months, saying, 'we do not want this to take years'. It overran by only two months.

The findings are clear. 'There is no demographic time bomb as far as long-term care is concerned,' commission chair Sir Stewart Sutherland announced. 'As a result the costs of care in the future will be affordable by the nation.'

Funding should be divided between housing, living and personal care costs. The report found that 'normal living and housing costs should be the responsibility of the individual according to their ability to pay'.

But personal care, which 'directly involves touching a person's body and is distinct from treatment/

therapy', should be free at the point of use, after a needs assessment, and funded by direct taxation.

Taxation is the 'most efficient way of pooling risk', rather than relying on individual savings or costly private insurance, the report concludes. It is 'the most efficient and fair way for individuals to pay and for the nation as a whole to share the costs'.

This uncompromising and not very New Labour stance is echoed by Sir Stewart: 'We have taken advice from the most eminent economists and we are confident that we have got our sums right.'

The report calls for a national care commission to oversee the system of long-term care. It would monitor demographic trends and spending, represent consumer interests and set national benchmarks. This would resolve existing problems with the 'confusing and complex' maze of services and funding that leaves many elderly people bewildered.

Many health service managers will agree that someone who needs help to have a bath cannot understand why it matters whether it is provided by social services or the NHS - and why they are charged for one but not the other.

The commission also suggests that a national care commission could collect reliable data on what is provided and who pays - something seriously lacking in the present system, the report notes.

So Mr Dobson's response has been bitterly disappointing for those hoping for a speedy solution. He says this is 'an issue on which there are no easy answers'.

He seizes on the commission's suggestion of 'an informed debate' on its recommendations and says the government's response 'must await the outcome of that debate'.

A DoH spokesperson adds that it is 'likely to be the end of the year' before any full response emerges.

But managers and doctors working at the sharp end say they need a swift decision.

North and East Devon health authority is set to appeal later this year against a landmark High Court judgement that all nursing care should be free under the NHS.

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Director of primary and community care Anthony Farnsworth can't comment on the court case, but says the Royal Commission report 'does have a bearing on the issues raised'.

'It would be in the best interests of the public and working relationships between health and social services if the issues around public policy in this field were resolved as soon as possible.'

Mr Farnsworth says there is 'a perversity in the fact that nursing care in nursing homes is means-tested and nursing care in hospitals and community settings isn't'.

'Clarification at a national level would be very supportive,' he adds.

The Association of Directors of Social Services also wants the government 'to sort out the national framework'.

But president Chris Davies says that will take time. 'It's for government to decide who pays for what, and ministers will want to think long and hard about that.'

Sally Greengross, director general of the charity Age Concern, says: 'The onus is on the government to move the debate on quickly with a clear timetable.'

Primary care group representatives also call for action. Michael Sobanja, chief officer of the NHS Primary Care Group Alliance, says his members needed 'a speedy response'.

'I understand the government's reluctance, but the current system has presented many difficulties for patients, families and health authorities.'

Commission member Professor Mary Marshall, director of the dementia services development centre at Stirling University, says the commission's work is 'remarkable in its near unanimity'.

Despite a note of dissent signed by two members, 'we were fully in agreement about the nature and extent of the challenge and about the need for a national care commission and national standards'.

The dissenting members, lawyer and Oxfam chair Joel Joffe and David Lipsey, political editor of The Economist, agree with 'much of the analysis and recommendations' in the report. They back the call for the means test, which decides if someone should pay for their own care, to be modified.

But while the main report recommends that the cut-off point for state help be raised from£16,000 of savings, including property, to£60,000, the dissenters suggest only£30,000.

They back the commission's call to remove the anomaly that means nursing home residents pay for nursing care while those in residential homes or their own homes do not.

But making personal care 'free for all those who are assessed as needing it would make matters worse', they comment. It would add to demand and 'weaken the incentive' for people to provide for themselves.

Instead they call for 'a more genuine public-private partnership in the provision of care', possibly using pensions to fund insurance for long- term care.

North Yorkshire HA finance director John Grimes says he is impressed by the 'innovative' ways of tackling funding suggested by the two dissenting commission members.

He says the commission itself 'failed' to deal with the 'extraordinarily' expensive system of long-term care. And making personal care free would 'add more to the bill', at a 'frightening cost'.

The Royal College of Nursing admits that there is 'a big cost implication'. But RCN general secretary Christine Hancock adds: 'A huge amount of time is currently wasted on determining whether a patient needs 'health' or 'social' care in order to decide who is going to pay, instead of simply assessing what is best for the patient.'

The NHS Confederation sees the report's estimated£1.1bn increase in current public spending as a problem.

Policy manager Tim Jones says: 'The devil is not in the detail, it is the global figure that is not to be found in the existing cost envelope.'

Mr Jones welcomes the commission's support for further development of pooled budgets between health and social care. The commission believes pooling would 'encourage the best use of money' with a 'client-centred approach'.

Mr Jones says the NHS is 'moving that way anyway' with the duty of partnership between health and local authorities in the Health Bill. He agrees that there are 'unacceptable variations and injustices in the way that some people have to fund their own care and others do not'. But he adds: 'If there was an easy solution we would have done it already.'

With Respect to Old Age. Royal Commission on Long-term Care. www.


See politics, page 17; legal

briefing, page 28.