King's Fund wants one national care assessment in England, cost not yet known

The decision on who gets care would stop being local

The King's Fund wants the decision on who gets long-term care in England to be made the same way everywhere. Its new framework, Equal access: a fairer system of social care support for England (opens in a new tab), proposes one national assessment and national funding for most long-term care.

This would change a great deal about how commissioners work at local level. Assessment and most of the money would move to national level, and councils would focus on joining up care with housing, health and other services.

The report points towards a national tariff for providers that could reflect the cost of a Fair Pay Agreement for care workers. Tariff rates have not yet been set out. This is a think tank proposal: it changes no law, eligibility rule or commissioning arrangement today.

Similar councils, very different decisions

Some councils support twice as many working-age adults with long-term care needs as statistically similar authorities, the King's Fund found. The share of people taking direct payments varies by more than fivefold between some areas.

The King's Fund does not call every gap unfair. It puts the variation down to differences in local demand, funding and assessment practice, and its answer is to take assessment out of local hands.

One national 'equal access' assessment would cover social care, NHS Continuing Healthcare, Attendance Allowance and carers' assessments. People would get a clear entitlement, taken as a direct payment or arranged at council level.

Wider access, with a co-payment and a cap

Around 220,000 people with social care needs in England are excluded from publicly funded long-term care by the means test and must meet their own costs, according to the King's Fund. About 1 in 7 people face care costs of over £100,000.

Under the model, anyone who meets a needs threshold would get publicly funded care with an individual co-payment, and a cap would limit lifetime care costs. How big that co-payment is decides almost everything else.

A price somewhere between £4bn and £18.5bn by 2036

The King's Fund cannot put one price on its model, because the cost depends on how much people pay towards their own care. The more they pay, the less the state does, and that choice has not been made.

A model close to a care-cost cap with means-tested support would cost around £4bn by 2036, on the Health Foundation estimates the King's Fund cites. A near-universal model with low or no co-payments would cost £18.5bn.

Until co-payment levels are set, nobody can say what the reform costs or what any one person would pay, so it cannot be read as a costed plan. The King's Fund plans to model specific cost and co-payment scenarios over the coming months.

How a national system is paid for, and what it covers, is the same question hanging over Prime Minister Andy Burnham's plan for a free national care service.

The big decisions have not yet been set out

Tariff rates, the level of the lifetime cap, how the needs threshold would be decided and how responsibilities would be split between central and local government have not yet been set out. Detailed workforce reform and an assessment of whether the provider market has the capacity to deliver are also still to come.

Those gaps matter to everyone in the funding debate: ministers deciding what to pay, councils deciding what is left of their role, providers waiting on a price, and the people who would pay the co-payment.

One national price, very different local costs

A single national tariff would have to cope with very different local costs. Councils in London pay much more for a care home place than councils in the North East.

A national assessment and tariff could also take away the flexibility councils now use to shape support around local need. Any tariff that ignores a gap like that would leave providers in the dearest areas paid too little, or those in the cheapest paid too much.

Agreeing on reform has never been the hard part

SCIE's interim chief executive, Gerard Crofton-Martin, described inequities in access as (opens in a new tab) "profound and persistent, and they demand urgent action." Fixing them, he added, would need "an honest conversation about funding." (opens in a new tab)

Agreeing that the gaps are unfair costs nothing. Paying to close them is another matter.

The King's Fund has mapped the lottery. Whether anyone will pay to end it is the question its next round of modelling has to answer.