Amid the generally positive reaction to the national plan for the NHS, a warier note has greeted the government's response to the report of the royal commission on long-term care. Presenting this as part of the national plan for the health service overall could be said to illustrate genuinely joined up thinking. A less charitable, perhaps more cynical, interpretation is that the less-than-joyous news was tucked inside to deflect attention.
The costs of nursing care will be met by the state. That is good news, up to a point. But note the careful use of terminology: "nursing" care is not the same as "personal" care, which the royal commission recommended should be funded.
In deciding to fund nursing care, the government has removed some of the worst anomalies in the system, but left others intact. Far from removing the arbitrary boundary between health and social care, it has been firmly reinforced.
How does the definition of nursing care differ from that of personal care? The commission adopted a perhaps simplistic interpretation, regarding personal care as that which "directly involves touching a person's body". Such a definition would encompass nursing care, but crucially it went wider and also embraced care delivered by a range of people - health care assistants, personal care assistants, therapists, and so on.
The national plan definition, on the other hand, which restricts nursing care to the time a registered nurse "spent on providing, delegating or supervising care in any setting", plays tautological and semantic games but threatens to rule out vital areas of highly personal and intimate assistance routinely provided by a range of care staff not supervised by registered nurses. These would include providing help with bathing, dressing, using the toilet, managing incontinence and even with eating and drinking.
Some of the problems applying the definition in practice are immediately evident. In particular, who will decide whether or not a person has nursing care needs, and on what basis? There is by no means consensus on what assessment of need should be used, how it should be done, or by whom.
Beyond that, a new set of perverse incentives could be introduced into the system. At present, the split between residential and nursing homes is often fairly arbitrary.
Introducing a greater subsidy to those needing nursing care runs the risk of ratcheting up the level of assessed need, and rewarding homes for having more dependent residents. Far from resolving problems on the health/social care divide, moreover, it reinforces incentives for cost shunting between health and local authorities.
In other respects, the proposals are also mixed. Disregarding the value of a house from means-testing for up to three months could give some people the chance for recuperation and a return to their normal life. But three months may be inadequate, and rehabilitation will only work if there is the development of intermediate services and skills to provide the right support.
The three-month period must be more than just "a breathing space" (as the national plan puts it) to consider the possibility of returning home; people need to reacquire the independence and health that will allow this to be practicable. The skills and know-how to bring this about are not in abundant supply.
While a substantial increase in the capital limits used in the means test had been expected, there is to be merely a restoration to the 1996 value. Allowing people to hold on to a greater amount of equity could have been an important concession. There is evidence, however, that the best way to help the very poorest people in care homes would have been to raise significantly the personal allowance (the amount of income which people are allowed to retain as so-called pocket money) from the minimal £15.45 a week to at least £30.
It can be argued that this is essential in allowing people to retain dignity; to allow them to buy clothes when they need them, to buy personal toiletries and to continue to buy the gifts for their friends and family (particularly grandchildren) which are so fundamental to human relations.
It has been said that nobody will any longer be forced to sell their home against their wishes. This, too, would be good news if it were true. While new arrangements to introduce a scheme to release equity to older householders will in effect prevent the sale of a house during their lifetime, the house will still need to be sold at death to repay the loan.
So, on balance, what verdict should be offered on the plans for long-term care? This was never going to be an easy issue to resolve, and previous administrations shrank from taking unpopular and difficult decisions. To its credit, the government has attempted to put in place a compromise which removes some of the most glaring and unjust anomalies. But the core recommendation of the royal commission has been rejected, and that is a tragedy.
Melanie Henwood is an independent health and social care analyst
