With Respect to Old Age:Long Term Care - Rights and Responsibilities


Executive Summary and Summary of Recommendations

The Commission have begun from the point of view that old age should not be seen as a problem, but a time of life with fulfilments of its own. To provide security in old age and proper care for those that need it our main recommendations are that:

  • The costs of long-term care should be split between living costs, housing costs and personal care. Personal care should be available after assessment, according to need and paid for from general taxation: the rest should be subject to a co-payment according to means. (Chapter 6)

  • The Government should establish a National Care Commission to monitor trends, including demography and spending, ensure transparency and accountability in the system, represent the interests of consumers, and set national benchmarks, now and in the future. (Chapter 7)

The Commission have sought to recommend a way of paying for long-term care which brings improvements in the short term and which is affordable and sustainable. It is a complex issue and none of the options are easy. Three key principles informed the approach we have taken:

  • Responsibility for provision now and in the future should be shared between the state and individuals - the aim is to find a division affordable for both and one which people can understand and accept as fair and logical;

  • Any new system of state support should be fair and equitable;

  • Any new system of state support should be transparent in respect of the resources underpinning it, the entitlement of individuals under it and what it leaves to personal responsibility.

The Commission conclude that doing nothing with respect to the current system is not an option. It is too complex and provides no clarity as to what people can expect. It too often causes people to move into residential care when this might not be the best outcome. Help is available to the poorest but the system leads to the impoverishment of people with moderate assets before they get any help. There is a degree of fear about the system which is of concern in a modern welfare state. It is riddled with inefficiencies. The time has come for it to be properly modernised.


The broad outline of the Commission's conclusions is as follows:

  • For the UK there is no "demographic timebomb" as far as long-term care is concerned and as a result of this, the costs of care will be affordable;

  • Long-term care is a risk that is best covered by some kind of risk pooling - to rely on income or savings, as most people effectively have to do now, is not efficient or fair due to the nature of the risk and the size of the sums required;

  • Private insurance will not deliver what is required at an acceptable cost, nor does the industry want to provide that degree of coverage;

  • The most efficient way of pooling risk, giving the best value to the nation as a whole, across all generations, is through services underwritten by general taxation, based on need rather than wealth. This will ensure that the care needs of those who, for example, suffer from Alzheimer's disease - which might be therapeutic or personal care - are recognised and met just as much as of those who suffer from cancer;

  • A hypothecated unfunded social insurance fund would not be appropriate for the UK system. A prefunded scheme would constitute a significant lifetime burden for young people and could create an uncertain and inappropriate call on future consumption;

  • The answer lies in improvement of state provision, but the state cannot meet all the costs of "long-term care" in the broad sense. The elements of care which relate to living costs and housing should be met from people's income and savings, subject to means testing, as now, while the special costs of what we call "personal care" should be met by the state. This would cost between £800 million and £1.2 billion a year (at 1995 prices);

  • Currently an estimated 2.2% of taxes from earnings, pensions and investments is spent on long-term care in residential settings and in people's homes. Improving entitlements in the way we propose will add 0.3% to this bill, rising to 0.4% in the middle of the next century;

  • Although people will still need to meet their living and housing costs should they need care, it will be clear what they will need to make provision for - and such provision will be affordable by more people;

  • Other options are available at lesser cost to make specific improvements to the current system. They include disregarding the value of the house in the means test for 3 months, changing the limits of the means test, and making nursing care wherever it is provided free. Each option would involve increases to current spending each year of between £90 million and £220 million;

  • Because of the uncertainty of the data, the lack of trust in the present system among older people, and the cynicism as to Governments' future intentions which exists amongst younger people, a new body, the National Care Commission, should be established. Its task would be to look at trends, monitor spending, ensure standards, and visibly represent the voice of the silent majority of consumers now and in the future;

  • The system needs more effective pooling of budgets, including bringing the budgets for housing aids and adaptations into a single pot;

  • The Commission recommend that more care is given to people in their own homes. Therefore the role of housing will be increasingly important in the provision of long-term care;

  • More services should be offered to people who have an informal carer;

  • More data should be collected on younger disabled people, to enable better planning of services, and the Government should consider the read-across from the provision of free personal care to the Independent Living Funds.

The Commission's report is intended to lead to a genuine modernisation of a system of financial support about which there is considerable disquiet and concern. We expect it will be given very careful consideration by Government, resulting in full debate within and across the countries of the United Kingdom on how a civilised society should meet the cost of caring for of its older citizens.

The Commission's recommendations represent a unique opportunity for a new contract between Government and people and between all generations of society. This will ensure that the nation's resources which are spent on the care of older people are more effective and will promote increased social cohesion and inclusiveness. If our proposals are accepted, the nation will have demonstrated that it values its older citizens and is prepared to give them freedom from fear and a new security in old age.


Our main recommendations:

  • The costs of care for those individuals who need it should be split between living costs, housing costs and personal care. Personal care should be available after an assessment, according to need and paid for from general taxation: the rest should be subject to a co-payment according to means. (Chapter 6)

  • The Government should establish a National Care Commission which will monitor longitudinal trends, including demography and spending, ensure transparency and accountability in the system, represent the interests of consumers, encourage innovation, keep under review the market for residential care, nursing care, and set national benchmarks, now and in the future.
    (Chapter 7)

    On funding we recommend:

  • The Government should ascertain precisely how much money, whether from NHS, Local Authority Social Services and Housing budgets, or from Social Security budgets, goes to supporting older people in residential settings and in people's homes. (Chapter 4)

  • The value of the home should be disregarded for up to three months after admission to care in a residential setting (with appropriate safeguards to prevent abuse) and the opportunity for rehabilitation should be included as an integral and initial part of any care assessment before any irreversible decisions on long-term care are taken. (Chapters 6 and 8)

  • Measures should be taken to bring about increased efficiency and improved quality in the system, including a more client centred approach, a single point of contact for the client with devolved budgeting, budgets shared between health, social services and other statutory bodies and greater integration of budgets for aids and adaptations. (Chapter 8)

  • The Commission set out a number of other changes to the current system, such as changing the limits of the means-test, or making nursing care free, which would be of value in themselves, but which would be subsumed by our main recommendation. (Chapter 6)

  • The resources which underpin the Residential Allowance in Income Support should be transferred to local authorities. (Chapter 4)

  • The Government should consider whether "preserved rights" payments in social security should be brought within the post 1993 system of community care funding, or whether some other solution can be found to address the shortfall in funding experienced by this group. (Chapter 4)

  • The Government's proposals on pooled budgets should be taken further, with pooled budgets being implemented nationally. (Chapter 8)

  • Budgets for aids and adaptations should be included in and accessible from a single budget pool and a scheme should be developed which would enable Local Authorities to make loans for aids and adaptations for individuals with housing assets. (Chapter 8)

  • The system for making direct payments should be extended to the over 65s, subject to proper safeguards and monitoring. (Chapter 9)

    On the provision of services we recommend:

  • Further research on the cost effectiveness of rehabilitation should be treated as a priority, but that this should not prevent the development of a national strategy on rehabilitation led by the Government to be emphasised in the performance framework for the NHS and Social Services. (Chapter 8)

  • Further longitudinal research is required to track the process and outcomes of preventive interventions and to assess their impact both on quality of life and long-term costs. (Chapter 8)

  • It should be a priority for Government to improve cultural awareness in services offered to black and ethnic minority elders. (Chapter 8)

  • The role of advocacy should be developed locally, with backing from central Government. (Chapter 8)

  • There should to be wider consultation on the provision of aids and adaptations and on what should under a new system be free and what should be subject to a charge. (Chapter 8)

    On help for carers we recommend:

  • Better services should be offered to those people who currently have a carer.
    (Chapter 8)

  • The Government should consider a national carer support package.
    (Chapter 8)

    On information and projections we recommend:

  • The National Care Commission should be made responsible for making and publishing projections about the overall cost of long-term care at least every five years. (Chapter 2)

  • The Government should set up a national survey to provide reliable data to monitor trends in health expectancy. (Chapter 2)

  • The Government should conduct a scrutiny of the shift in resources between various sectors since the early 1980s, and should consider whether there should be a transfer of resources between the NHS and social service budgets given changes in relative responsibilities. (Chapter 4)

  • A more transparent grant and expenditure allocation system should be established. This is a task which could be referred to the National Care Commission. (Chapter 4)

  • Further longitudinal research is required to track the processes and outcomes of preventive interventions and to assess their impact both on quality of life and long-term costs.
    (Chapter 8)

    In relation to younger disabled people we recommend:

  • In the light of the Commission's main recommendations, the Government should consider how the provision of care according to need would relate to Independent Living Fund provision for the personal care needs of younger disabled people. (Chapter 9)

    Implementing the Commission's recommendations:

  • Many of our recommendations can be implemented without the need for primary legislation. Examples include the disregard of housing assets for the first three months, changing the means-test limits, or extending the provision of free nursing care. The National Care Commission could be established as a shadow body within Government. We would urge the Government to implement our proposals as soon as possible. The need for change is pressing.

The full text of the Commission's report is available on the Royal Commission's website at www.open.gov.uk/royal-commission-elderly/

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Prepared 1 March 1999