Tuesday, August 15, 2017

The Politics of Elder Care, Social Care, and the “Dementia Tax”: A View from the United Kingdom

By Richard Ashcroft

Professor Richard Ashcroft, an AJOB Neuroscience Editorial Board member, teaches medical law and ethics at both the undergraduate and postgraduate level in the Department of Law at Queen Mary University of London.

The United Kingdom has recently gone through a General Election. The main reason the election was called by Prime Minister Theresa May was to secure a stronger mandate for the ruling Conservative Party, which was governing with a small overall majority of 19 seats over the Opposition parties. PM May’s argument was that in the negotiations with the other member states of the European Union over the UK’s exit from that Union (Brexit), an increased majority would give her a stronger bargaining position. As the election turned out, the electorate returned the Conservatives with fewer seats, and PM May had to form a minority administration, with a partial agreement to support the Conservative Party made with one of the smaller parties, the Democratic Unionist Party, which only contests seats in Northern Ireland. As a result PM May has a working majority, but one that is more fragile, rather than stronger.

Commentators have suggested a number of reasons for this outcome, but there seems to be general agreement that a turning point in the electoral campaign was the release of the election manifesto of the Conservative Party. While there are many reasons that might explain the downturn in support for PM May, one particular policy announced in the manifesto, deemed the “dementia tax,” attracted widespread criticism. 

UK population distribution.
Image courtesy of Wikimedia Commons.
The manifesto identified five key challenges for the UK, and policies to address these. One of the five is “The Ageing Society.” (The other four were: a need for a strong economy; Brexit and a changing world; enduring social divisions; and fast-changing technology). The ageing society is addressed in chapter 4 of the manifesto, which notes that “our system of elderly care is not working for the hundreds of thousands currently not getting the dignified and careful attention they deserve, nor for the people and organisations providing that care, nor is it sustainable for today’s younger people who will potentially face care costs themselves. It is not fair that the quality of care you receive and how much you pay for it depends in large part on where you live and whether you own your own home.” (p.64) 

This is a good summary, I think, of the consensus that has formed over the past few years about the nature of the financial problem facing social care in the UK. To understand the practical context for this, it is important to note that in the UK health and social care are separate systems. Whereas healthcare is financed (by and large) by the state centrally, mainly through publicly owned and managed providers (together referred to as the NHS), social care is, for the most part, delivered privately, with costs partly or wholly offset by funding through local government, subject to means testing and a variety of user charges. In some cases, a patient or service-user will get some care free, because it is delivered by and through the NHS; whereas another patient or service-user might get exactly the same type of care, but have to pay for it because it is delivered through the social care system. Some care is delivered in the patient or service-user’s own home (domiciliary care) and some is delivered through residential social care and some again is delivered in hospitals. While any changes in the finance or delivery or quality of health care quickly become headline news in the mass media, similar changes in social care rarely attract the same attention. A useful history of why we have this complex situation, which can fairly be described as a mess, is Nick Timmins’s The Five Giants: A Biography of the Welfare State (London: Harper Collins, 2001 [2nd edition]). 

Returning to finance, the Conservative manifesto says:
“Under the current system, care costs deplete an individual’s assets, including in some cases the family home, down to £23,250 or less. These costs can be catastrophic for those with modest or medium wealth. One purpose of long-term saving is to cover needs in old age; those who can should rightly contribute to their care from savings and accumulated wealth, rather than expecting current and future taxpayers to carry the cost on their behalf. Moreover, many older people have built considerable property assets due to rising property prices. Reconciling these competing pressures fairly and in a sustainable way has challenged many governments of the past.” (p.65) 
Image courtesy of Flickr user Myfuture.com.
Again, this is an apt diagnosis. Some elderly service-users are able to finance their care from income; typically these are the most wealthy, in particular those with high investment income or high occupational pensions. Others, whose income may be less, may be able to finance their care out of savings. A significant proportion, however, hold neither high paying occupational pensions nor hold significant savings, and their largest single capital asset is their homes. 

What the Conservative Party proposed was:
“First, we will align the future basis for means-testing for domiciliary care with that for residential care, so that people are looked after in the place that is best for them. This will mean that the value of the family home will be taken into account along with other assets and income, including value in the family home.   
“Second, to ensure this is fair, we will introduce a single capital floor, set at £100,000, more than four times the current means test threshold. This will ensure that, no matter how large the cost of care turns out to be, people will always retain at least £100,000 of their savings and assets, including value in the family home. 
“Third, we will extend the current freedom to defer payments for residential care to those receiving care at home, so no-one will have to sell their home in their lifetime to pay for care.” (p.65)
It was this financial proposal that received widespread criticism in much of the news media, from commentators on the political Right as well as in the Centre and on the Left. Many commentators focused on the shift from previous policy, which set a cap on how much an individual would have to pay before the state stepped on (as announced on p.65 in the Conservative Party’s manifesto for the 2015 General Election, following the recommendations of Sir Andrew Dilnot in his report to the then Conservative-Liberal Democrat coalition administration in July 2011). The proposal in the 2017 manifesto proposes a floor. The 2015 manifesto proposed that no one should pay more than a certain amount – undefined, but often quoted as being about £72 000. 

So if you held assets of say £500,000, you would be left, at death, with assets of about £428,000. Under the 2017 manifesto, you would pay out until you had £100,000 left. And while in the 2015 commitment your house would, under most circumstances, be ring-fenced from assessment, in 2017 it would not. This is a very significant difference, at least on paper. 

Image courtesy of Flickr user
American Advisors Group.
Other commentators highlighted the way bringing the home into the means test was unacceptable for other reasons: both because it is important to many families to be able to pass on the family home from parents to children, and because of the above noted point that the home is often the joint home of a couple or family, not simply the asset of the person needing care to be disposed of (even after their death in deferred settlement of care costs). 

The proposal quickly became labelled the “dementia tax.” This highlighted another politically contentious problem, and one of particular interest to the readers of this blog: crudely put – if you are dying over a period of some years of cancer, then all your care is funded by the NHS, with some services provided by charities which typically do not charge patients. Most palliative care is also free. 

Some domiciliary care may also be provided, which may attract charges, but family carers can get welfare benefits and other support. In other words, cancer is treated as an illness and is fully under the health service umbrella, provided free at the point of use and funded through general taxation (and to some extent through charitable giving). On the other hand, if you are dying of Alzheimer’s or Parkinson’s disease, although your medical care will be supervised through the NHS, in general you are treated as needing social care, and this you have to pay for up to the point where you pass through the means-test threshold. 

Thus, disorders such as Parkinson’s and the dementias are not treated as health conditions but as social needs. 

Image courtesy of Wikimedia Commons.
And moreover, in the current state of medical knowledge, neither is preventable or even predictable; thus, there is no obvious reason why this distinction should be drawn where it is, or why one should attract high costs payable by the patient and his or her family and the other does not. 

In the aftermath of the highly critical reception of this proposal, PM May was reported to have announced that there would, after all, be a limit on how much people were going to have to pay. 

After the election, when the new administration was finally formed and its legislative platform was announced to Parliament in the traditional Queen’s Speech, the social care had been dropped. 

The other main parties had also considered social care in their manifestos. The Labour Party proposed to “lay the foundations for a National Care Service” (p.72), although much of the detail on financing was to be worked out through “consensus on a cross-party basis about how it should be funded.” The Liberal Democratic Party also announced general reforms, in particular the implementation of a cap on social care costs to patients, but focussing mainly on structural reforms, and without much detail on financing. And the Scottish National Party, which went into the General Election as the third largest party in Parliament, committed to continuing “free personal care for older people” (which as the governing party in the Scottish Parliament it is able to control following Scottish devolution in 1999) but made no commitment on residential care, (p.5). 

What can we learn about social care from this short tour through our recent general election? First of all, we learn that it is a high risk political issue, which three of the four main parties handled, as it were, with asbestos gloves, and the fourth party, which entered the election expecting to win handsomely, decided to make a central part of its platform. It then discovered that unless carefully thought through and consulted upon, social care could be a political issue which, far from being a minority issue, could turn an election campaign sour very quickly. No one had predicted, when the election was called, that social care would turn out to be one of the key defining issues. What should perhaps have alerted politicians to its importance is the well known findings that older people are more likely to vote and that older people are more likely to vote Conservative. These data from polling company YouGov give the picture. 

Image courtesy of Wikimedia Commons.
Social care financing is a complex issue, and the technical details are not generally well known. Policy debates about social care financing rarely get into the mainstream media. And, to be frank, even philosophers and economists find debates about intergenerational equity… difficult. That said, it is not immediately obvious that older voters are unreasonable in their demands or would necessarily disagree with the solidarity argument laid out in the Conservative manifesto. Their resistance to the specific proposals would likely involve a complex narrative involving the emotional and family importance of their homes, their fear of dementia, concern with the quality of social care provision, concern for their legacy to their children, and so on— which does not pick out a clear policy path to follow. 

And yet, as the Conservative manifesto makes clear, “the ageing society” is one of the defining political and ethical challenges of our era. 

The status quo is riddled with incoherence and injustice, which everyone acknowledges, and to this extent the Conservative Party deserves a degree of non-partisan applause for seeking, however unsuccessfully, to lay this before the electorate. 

A concluding challenge, then, for ethicists: this episode should make it strikingly clear that we should be playing our part to clarify the social and health policy challenges of ageing, and perhaps especially those challenges associated with the currently hardly treatable, unpreventable and unpredictable diseases of brain and mind, and to work with economists and public policy scholars to devise ethically sound options. Inevitably there will be political debate about which path to go down. But political debate is imperative here; political silence cannot be allowed to resume.


Want to cite this post?

Ashcroft, R. (2017). The Politics of Elder Care, Social Care, and the “Dementia Tax”: A View from the United Kingdom. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2017/08/the-politics-of-elder-care-social-care.html

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