It used to be pretty straightforward: healthcare was free at the point of delivery and you paid what you could afford for social care based on a national system for residential care and a discretionary local system for care at home.
The Care Act is trying to tidy up social care with national rights and clearer entitlements. There is a sharper focus on prevention, wellbeing, integration and personalisation. At its heart is a new commitment to cap costs for the better off and to allow everyone to defer payment for residential care.
But will it make charging simpler and more transparent?
The act does not change the current continuing healthcare boundary between local authority responsibilities and those of the NHS but in practice the development of integrated models of care outside hospitals has blurred this. Rather than charge for such services, councils have chosen to forgo possible income.
Similarly, councils have not charged for preventative services, including carers’ support. The act gives carers the right to services that help them care and the government believes this approach will generate savings to help offset additional cost pressures.
Draft guidance leaves the door open to charging for such services. I think that would be a mistake but it creates further confusion.
The charging elements of personal budgets have also created ambiguities, where some elements attract a charge and others do not.
The act offers the option of deferring payments for residential care to everyone, while allowing councils to charge interest for the first time. Councils have already expressed concern about recovery rates and cash flow. It is irrational not to extend this to those with similar high levels of need who are supported in the community.
The government recognises that advice on choosing the deferred payment falls within the scope of financial services legislation. Draft guidance recommends advice should be available, independent of both the council and any other financial institution offering alternative products.
The biggest test for the new system though may come from arrangements to cap costs for self-funders. Councils will need to calculate the cost of the support package they have been assessed as needing and that will be credited each week until the cap is reached. This will require transparency about the unit cost of each element of the service paid by the council.
This will smoke out tough issues about variations in costs between in-house and commissioned services and about how current charges often bear no relation to actual costs. Self-funders trying to arrange their own care in the local market will find that real costs quoted to them are higher.
All this suggests more complexity and fresh battles ahead.
Andrew Cozens is an independent social care and health specialist