'Where next for care?' ILC-UK and the Actuarial Profession Day Conference supported by Partnership

Where Next for Care?

18 October 2011

Welcome

Baroness Sally Greengross, ILC-UKJane Curtis, Institute and Faculty of Actuaries

The Future of Care Funding

Andrew DilnotCommission on Funding of Care

and Support

Conclusions and recommendations of the Commission on Funding of Care and Support

Fairer care funding

The Commission’s remitThe Government asked the Commission to recommend:

– how best to meet the costs of care and support as a partnership between individuals and the state;

– how people could choose to protect their assets, especially their homes, against the cost of care;

– how, both now and in the future, public funding for the care and support system can be best used to meet care and support needs.

Setting the context

The number of older people is increasing

65-69 70-74 75-79 80-84 85+

Growth in the number of older people in England 2010-2030

Flexible societies are good at adaptingProportion of UK population aged 65 and over

1901 1921 1939 1961 1981 2001 2021

Social care is one element of state supportPublic spending on older people in England 2010/11

Social security benefits

Social care

£50bn

£100bn

£150bn

Funding has not kept up with demandExpenditure and demand: older people’s social care (2009/10 prices)

Expenditure

Demand

£6.0bn

£6.5bn

£7.0bn

£7.5bn

£8.0bn

2005/06 2006/07 2007/08 2008/09 2009/10

Care costs are uncertain and can be very highExpected future lifetime cost of care for people aged 65 in 2009/10

£100k

£150k

£200k

£250k

£300k

0% 20% 40% 60% 80% 100%

Fear is the natural response to current system Maximum possible asset depletion for people in residential care

5% 25% Median 75% 95%

£0k £50k £100k £150k £200k £250k £300k £350k £400k £450k £500k

Assets on going into care

Percentiles of housing wealth

£150k lifetimecost

£100k

A cap removes the risk of very high costsExpected lifetime costs for people going into care in 2010/11, by percentile

£100k

£150k

£200k

0% 20% 40% 60% 80% 100%

A cap removes the risk of very high costsExpected lifetime costs for people going into care in 2010/11, by percentile

£100k

£150k

£200k

0% 20% 40% 60% 80% 100%

And offers significant asset protection Maximum possible asset depletion for people with £150k residential care costs

5% 25% Median 75% 95%

£0k £50k £100k £150k £200k £250k £300k £350k £400k £450k £500k

Current system

£35k cap

But we also need to reform the means testThe effect of extending the means test on the amount of support people receive

Currentsystem

£0k £25k £50k £75k £100k £125k

But we also need to reform the means testThe effect of extending the means test on the amount of support people receive

Reformed system

Currentsystem

£0k £25k £50k £75k £100k £125k

Extending the means test helps the poorestMaximum possible asset depletion for people with £150k residential care costs

5% 25% Median 75% 95%

£0k £50k £100k £150k £200k £250k £300k £350k £400k £450k £500k

Current system

£35k cap

Extending the means test helps the poorestMaximum possible asset depletion for people with £150k residential care costs

5% 25% Median 75% 95%

£0k £50k £100k £150k £200k £250k £300k £350k £400k £450k £500k

£35k cap with extended means test

Current system

The reforms reduce the costs individuals face

Initial level of wealthMaximum spend on care

£40,000

£50,000

£70,000

£100,000

£150,000

£9,000

£12,000

£18,000

£28,000

£35,000

Care for people of working age

Age Maximum spend on care

Under 40

40 to 50

50 to 60

60 to 65

Free care

£10,000

£20,000

£30,000

£35,000

General living costs− People in residential care would need to

make a contribution towards their general living costs (such as food and heating).

− People have to pay these costs if they live at home.

− Believe this contribution should be fixed - recommending between £7,000 and £10,000 p.a. (as the maximum possible contribution).

All spending: £697bn

NHS: £103bn

Social security for older people: £85bn

Education: £61bn

Defence: £44bn

The cost of reform: £2bn

Social care and disability benefits for adults: £27bn

We are also recommending other reforms− A major campaign to improve

information and advice

− Better information and needs assessments for carers

− More consistent, portable assessments with a national eligibility threshold

− Better integration of health and social care

We also think there will be an opportunity for the financial services sector to help people with their contributions.

Thank youCommission on Funding of Care and Supportwww.dilnotcommission.dh.gov.uk

Who benefits from the reforms?Public expenditure on social care, by income quintile

£0.0bn

£0.5bn

£1.0bn

£1.5bn

£2.0bn

£2.5bn

Bottom 2 3 4 Top

Reforms

Current system

Who benefits from the reforms?Additional public expenditure as a proportion of income, by income quintile

Bottom 2 3 4 Top

Who could pay for the reforms?Additional tax paid, as a percentage of income, if reform were funded through direct taxes, by household income quintile

The Future of Care FundingPanel Debate

Andrew Dilnot Julia Unwin, JRF

Jane Ashcroft, Anchor Jules Constantinou, Gen Re

Paying for Care: The International Context

Dr. Doug AndrewsUniversity of Southampton

Paying for Care:The International

Context

Doug AndrewsUniversity of Southampton

October 2011

Overview

• The views expressed are mine and not necessarily those of my employer or any professional body of which I am a member

• Provide background on a project in progress for the Actuarial Profession

• Outline differences in approaches to funding

• Draw some conclusions about insurance

Objective of Actuarial Profession’s Project

• To identify gaps in the publicly available literature regarding LTC, particularly with respect to funding

• Actuarial Profession wishes to be in position to play its part in the public interest by working collaboratively with other bodies and disciplines to develop long term solutions

Background on Project• University of Southampton

awarded project based on a response to a call for proposals

• Large research team & partnering required

• ILC-UK conducted primary research for 5 countries

• NASI conducted primary research for USA

• Andrews, Power, Stott – key report writers

• 5 other researchers & many expert reviewers contributed

Steps in the Process

• Conduct primary research• Produce gap analyses• Write interim report• Forum held Oct. 14 to provide

input to the Actuarial Profession• Write the final report

Primary Research• Gathered information on 10

countries• Developed a template based on

information requested • Used a referencing approach for

both general and country-specific references

Types of Gap Analysis

• Gaps in publicly available information regarding LTC data and information

• Gaps in the use of Private Financial Services Solutions (PFSS) by country

Oct. 14 Forum Considered

• Data and gaps identified, especially in respect of funding LTC and the development of PFSS

• Opportunities for collaboration to contribute to the development of funding and PFSS solutions and to provide information regarding the costs and benefits of implementing Dilnot’s recommendations

Spectrum of Funding Approaches

• Norway – largely state provision but unfunded

• Germany – compulsory funded national insurance

• In between – mix of state provision, self funding, and PFSS

• Adopting Dilnot would increase state provision and reduce self funding required

Developed Pre-funding: Singapore’s ElderShield

• Provides for people with severe disabilities

• Covers residential facilities or home-based costs but on indemnity basis

• Premiums paid from age 40• Means-tested subsidies• 3 private insurance providers• Minimal state provision –

personal responsibility

Developed Pre-funding: USA

• Highly fractured financing system

• Medicaid available to those of very low means

• Comparatively large PFSS market• Traditional PFSS products:

gradual shift from reimbursement to cash benefits

• Other PFSS include disease-specific insurance, annuities and reverse mortgages

Developed Pre-funding: Japan

• 79 aspects of health assessed • Determines eligibility for 7 levels

of support• Financing is shared

responsibility: 50% from public funds & 50% by premiums (age 40)

• Accommodation, utilities & meal expenses excluded from insurance benefit

• Sickness Hospitalization Insurance most common followed by Cancer Insurance

• PFSS market is shrinking

The Pressure of Demographics

• Countries with greater aging challenges have tended to take more action

• OASR indicates actives per elder (65 and up)

• Japan: 2.63 in 2010, 1.24 in 2050• Germany: 2.98 in 2010, 1.56 in

2050• Norway: 3.97 in 2010, 2.28 in

2050• UK: 3.60 in 2010, 2.41 in 2050• USA: 4.61 in 2010, 2.58 in 2050

Questions Regarding the Mix

• Different countries have different preferences for government-provided and mandated approaches

• All countries recognize that family should play some role

• Mental health needs to be addressed

• Upper bound of 4% of GDP for all care costs – but how should the cost be borne?

Reasons Given for Not Purchasing PFSS

• Price too high• May not require care• Uncertain what the state will

provide & often over-estimate state provision

• State provision may change by the time care is required

Concluding Observations Regarding Dilnot

• Would define state provision• Would specify the extent of the

individual’s responsibility• Would remove questions

regarding eligible expenses• All positives for a PFSS market• Questions remain about the cost

Lunch BreakAfternoon session will resume at 13.15

Welcome Back

Housing and Care

The Role of Extra Care

Dr. Dylan KnealeILC-UK

The International Longevity Centre-UK is an independent, non-partisan think-tank

dedicated to addressing issues of longevity, ageing and population change.

The role of Extra Care: Perspectives from three Extra Care Housing Providers

Dylan Kneale

ILC-UK and Actuarial Profession Day Conference, October 18th 2011

• Housing:

• Lived in same house for 40+ years (17% 1993/4; 24% 2007/8)

• Rising levels of under occupancy?

• Rising levels of housing wealth?.....Rising inequality? (Older people

still biggest consumers of social housing)

• Less retirement housing being constructed

• Health care:

• Compression of morbidity? (Zaninotto et al 2010)

• Non communicable diseases (stroke, dementia)

• Social Care:

• Rising cost; Unequal provision; Who pays?

• Rates of receipt of domiciliary care at home declining…

Health, social care and housing among the ageing population

What is it? Little consensus….

Wide spectrum of self-designated extra care housing

Some common principles of extra care housing:

Ergonomically designed

Flexible and continually adapting care packages delivered onsite

Communal facilities

Group activities

Independent homes within small-medium sized retirement communities

Usually age specific

Leasehold tenure as well as rental tenure

Community balance of care needs

Extra care housing

What do we know about extra care housing?

Research Questions 1. What is the social profile of extra care housing

residents and how does this compare with residents in the

community setting?

2. Can extra care housing be considered a home for life

for older people?

3. Does residence in extra care housing facilitate healthier

and more independent life?

4. What impact does residence in extra care housing

have on the uptake of overnight hospital beds?

5. What inferences can be made about the costs and

benefits of extra care housing?

Data and Methods Data: Longitudinal data from 3 partners on almost 4,000 residents of extra

care housing since 1995;

British Household Panel Survey; English Longitudinal Survey of Ageing;

Survey of English Housing (descriptive)

Limitations/Challenges

1. Characteristics of residents Descriptive analysis

2. Extra care housing as a home for life

Event history analysis (Lognormal and Competing Risks); Propensity Score Matching

3. Extra care housing as a healthy home for life

Event history analysis (Competing Risks); Propensity Score Matching

4. Extra care housing and hospital beds?

Zero inflated negative binomial regression; Propensity Score Matching

5.N Inferences on the costs and benefits of extra care housing?

Descriptive analysis

Gender

Living arrangements

Additional care needs

Health shocks that may predict entry to extra care housing:

Stroke

Dementia

Parkinson’s disease

Characteristics of residents

Extra care as a home for life I Length of time until exit (all exits)

First quartile (25%) Median (50%)

All residents 3.1 6.5

GenderMale 2.6 6.0

Female 3.4 6.7

0 5 10 15analysis time (years)

No additional care needs on arrival Very low care needs on arrival

Low - Moderate care needs Moderate to High care needs

High care needs on arrival Very high care needs on arrival

Proportion of extra care residents remaining

Extra care as a home for life II: Competing Risks Framework

Risk 1: moving to an institution

Risk 2: death

All residents 8.2% (6.7-9.9) 25.0% (22.4-27.5)

GenderMale 6.4% (4.3-9.1) 30.6% (26.0-35.3)

Female 9.1% (7.2-11.3) 22.0% (19.2-25.1)

Health Status/Care Needs on Arrival

No additional support package

5.5% (4.0-7.3) 16.8% (14.2-19.6)

Level 1 (very low package needs)

12.8% (6.8-20.8) 29.6% (20.0-39.7)

Level 2 (low support package)

17.5% (11.7-24.4) 39.8% (31.6-47.6)

Level 3 (moderate support package)

11.9% (5.2-21.5) 41.0% (28.3-53,1)

Level 4 & 5 (high or very high support package)

9.9% (4.9-17.1) 56.9% (46.1-66.3)

Age Group

50-64 6.8% (2.8-10.9) 10.2% (5.8-16.3)65-69 6.2% (3.1-11.0) 13.0% (8.2-19.1)70-74 6.0% (3.4-9.8) 18.2% (13.3-23.7)75-79 9.0% (5.8-13.0) 24.6% (19.4-30.2)80-84 8.0% (4.8-12.3) 27.2% (21.3-33.5)85+ 12.7% (8.5-17.7) 49.0% (41.8-55.8)

N 1,189 1,189

Extra care as a home for life III All community match sample Domiciliary care match sample

Age 65+

Model 1

Age 75+

Model 2

Age 80+

Model 3

Age 65+

Model 4

Age 75+

Model 5

Age 80+

Model 6

Models adjusted for Age, Sex, Living Arrangements, Year

Sub-hazard ratio of

moving to an institution

Sub-hazard ratio of

Extra care housing

1.776 1.216 0.905 0.694 0.532* 0.316**

(0.659) (0.471) (0.463) (0.207) (0.167) (0.121)

N 1714 1034 624 1630 1028 634

Diminution in loss of functional ability?

Extra care as a healthy home for life0.0

0 2 4 6 8 10analysis time

No additional care needs on arrival Very low care needs

Low-moderate care needs Moderate-High care needs

High to very high care need on arival

Time to increase in care package

Conceptualising ‘risk’ of health improvement

Extra care as a healthy home for life

Risk: improvement in health (decrease in care needs)

All residents 24.0% (20.6-27.5)

GenderMale 25.7% (19.5-32.3)

Female 23.8% (19.3-27.5)

Health Status/Care Needs on Arrival

No additional support package 30.8% (24.7-37.1)

Level 1 (very low package needs) 16.3% (9.4-24.8)

Level 2 (low support package) 26.0% (19.1-33.5)

Level 3 (moderate support package)

15.3% (7.5-25.6)

Level 4 & 5 (high or very high support package)

14.9% (7.9-24.0)

Village or Court developmentCourt 9.2% (5.8-13.7)

Village 32.1% (27.4-36.8)

Falls (fractures), stroke and heart disease account for the

main financial burden of older people’s health care

Within extra care setting, most accidents represent falls (“loss

of balance”, “got up too quick”, “turned around”)

Ergonomic adaptations? Group exercise classes?

Compare rates for small sample size with sample from ELSA

Matching indicative of a lower rate in extra care (49% vs 31%)

Sample size – caution – indicative evidence

Men susceptible to falls in extra care setting?

Falls in extra care

Extra care and overnight hospitalisation I Number of available beds for geriatric medicine declined by 61% (1987-

2008); Bed blocking an issue

Comparison group

Inverse care law – evidence in BHPS (or other effect?)

Incidence rate is higher than in overall community sample BUT reflects

length of stay

Number of episodes of admission consistently lower in extra care sample

i.e. less people go to hospital in the extra care sample, but those that do

stay longer

Closely matched comparison group overall incidence lower in extra care

sample

Mechanism?

Extra care and overnight hospitalisation II

65+ 75+ 80+ 65+ 75+ 80+Full community sample Advantaged community sample in receipt

of domiciliary care

ControlExtra care

Extra care and inferences on costs

Social care costs (median community care package and extra care)

Extra care and inferences on costs II

Initial social care costs of extra care housing may be higher

than if remaining in the community

But, because of higher probability of transition to institutional

accommodation , long-term costs lower

– Planning for retirement

Cost of lower rate of hospitalisation

Cost of reduction in package

Extra care housing:

1. Supports some of the most vulnerable in society

2. Appears to be a home for life for the vast majority

• Compared to those with similar characteristics appears to be

lower rate of transition to institution; plausible mechanism (age,

living arrangements, gender, in receipt of care at home)

3. Associated with fewer inpatient stays

4. Associated with fewer falls

5. Is a healthy home for life

Conclusions

Policy Recommendations I1. Policy-makers need a co-ordinated response to providing housing,

health care and social care for our ageing population.

2. Policy-makers should make specific pledges to increase the level of

provision of extra care housing.

3. The proposed National Planning Policy Framework should champion far

more robustly the housing needs of older people.

4. Policy-makers should recognise and encourage private sector

development of extra care housing.

5. The findings in this report suggest that policy-makers drafting the Health

White Paper should explicitly consider and make specific pledges to

increase the role of housing with care.

Policy Recommendations II6. Policy-makers should enhance and sustain programmes of education and information

for those who are retired and newly retired to plan their housing and financial futures.

Furthermore, consumers need reassurance that policy changes will not negatively

impact their retirement decisions.

7. Any National or Local Falls Prevention Strategy should include housing as a key

component of preventing further falls.

8. Receipt of Attendance Allowance opens a gateway for many older people to access

extra care housing, through helping to finance monthly care costs and to help access

other benefits. We would urge policy-makers to ensure that all who are eligible to claim

Attendance Allowance do so which could enable greater numbers of older people to

support a stay in extra care housing.

9. Further research is needed into the extra care housing sector.

Full report available:

www.ilcuk.org.uk

Further information:

Dr Dylan Kneale, International Longevity Centre

dylankneale@ilcuk.org.uk

Thanks for your attention

Housing and Care

Julia UnwinJoseph Rowntree Foundation

Housing and CareJulia Unwin, Chief Executive, Joseph Rowntree

Foundation and Joseph Rowntree Housing Trust

Our purposeSearch

Demonstrate

Influence

Our work programmes and aimsPove

rty • to examine

the root causes of poverty, inequality and disadvantage, and identify solutions

• to contribute to the creation and development of strong, sustainable and inclusive communities

• to identify ways of enabling people and communities to have control of their own lives

Housing matters

Care and repair

Not just about older people

Our credentials

Extra-care housing

Roles and responsibilities contestedDecisions to move inNominations and allocations decisionsDifferent expectations of housing with careBuildings and facilities provision, management

& maintenanceHealth and safetyPromoting well –beingSafe-guarding and duty of careManaging increasing care and support needsMoving on and end-of-life

Common cross-cutting issues

Regulation, complaints, user consultation and involvement

Costs and affordability

Older people’s preferences being overlooked or not heard

ConclusionHousing with care not a solution for everyone

But is a valuable option

Better housing and support for older people is needed

We need a range of housing, health and social care services for the whole ageing population – across generations and across different stages of our lives

Joseph Rowntree Foundation

Visit our website www.jrf.org.uk

www.twitter.com/jrf_uk

www.twitter.com/juliaunwin

www.facebook.com/JosephRowntreeFoundation

Housing, Wealth and Care

Jon KingMore 2 Life Ltd

Introducing

Jon King

Managing Director

More 2 Life Ltd

Structure

KRS Group(Holding Company)

Equity Release & Care Fees Lifetime Mortgage Lender Planning Service

• Link between Equity Release/Care

• Problem of resident status in the home

• Gradual move to domiciliary care

• Estimated 750bn of housing wealth held by people 65 years and over*

* Source – KRS Group

Historical Perspective

• 84% of those aged 65 years and above would choose care in the home

• One in five people aged over 65 could pay the £35,000 cap proposed in Dilnot

• Only 2% of the over 65’s have made financial provisions for ill health in retirement

Key Retirement Solutions Research

• Products designed to meet needs

• Flexibility

• Draw down products

• Impaired terms - underwritten

Product Development

Conclusions

• 1.4 million hours of care bought each year

• Important future for Equity Release in care funding

• Further product innovations needed

• £4 trillion in housing wealth overall in the UK,

which double the value of our pension assets*

* Source - FT

Final Thought…

Housing and Care Panel Debate

Andrea Rozario, SHIPJulia Unwin, JRF

Dylan Kneale, ILC-UKJon King, More 2 Life Ltd

Care Funding: The role of the private sector

Otto ThoresenAssociation of British Insurers

Steve GrovesPartnership

The Role of the Insurance SectorSteve Groves 18 October 2011

The Role of the Insurance Sector I am going to jump around a little!!! Aim to identify the role of the insurance sector over the

medium to long term To address question requires consideration of three not

necessarily aligned groups

– Consumers

– Policymakers

– Insurers

Taking the policy environment as read given previous speakers

The Dilnot Review

Much to welcome

– National assessment

– Public Debate about Care

– Need for better information and Advice

Overall adds an important third option to the debate

Some Concerns

– Widely misinterpreted

– Complex to implement

Statement of the Incredibly Obvious........

“The role of the Insurance Sector

is to take Insurance Risk”

[Steve Groves, FIA]

The Traditional Small Print.....

Care Annuities at point of need are a classic insurance proposition

– On an individual basis the outcome is highly uncertain

– On a portfolio basis its relatively predictable (for those with 15years of high quality data)

– Insurance industry exists to pool these risks and allow consumers to swap uncertainty for certainty

Pre-Funded Care Insurance actually has two problems to overcome:

– No one wants to buy it

– No one wants to provide it

Why Immediate Needs Annuities WorkConsumer Customer understands need; no longer an issue

with denial / priorities Simple to explain Deal known at outset; no subjectivity No claims assessment – automatically pays until

death No uncertainty over future social and political

landscape Reasonable Tax treatment

Insurer Adequate information to assess likely insurance risk

Why Pre-Funded Care Insurance doesn’t WorkConsumer Denial; “It will never happen to me” Prioritisation; “Live for today” Claims assessment; scepticism that insurers will pay out Reviewable premiums Too Complex Economic Free Riders

Insurer Impossible to assess insurance risk accurately enough to guarantee

terms Guessing how many people will claim And how long they will live in claim Over a 50 year plus timeline So product have reviewable premiums and deal is not known at outset

If I were Minister for Social Care Accept Consumers will not save specifically for Care

Focus on Middle England

– Poorest will always be state funded

– Richest will always be self funded

Drive ISA and Pension Savings

– Woefully low at the moment

– More assets in the hands of retirees is key to a medium term solution

Tackle Free-Rider Issues

– Want people to save and secure guaranteed income via either Pension or Care annuities

– Free up product regulations so pension annuities can be more efficient for care funding

– Partnership model via Disregard on Guaranteed Income (analogous to MIR in Pension Reform)

Therefore the Role of the Insurance Industry is....... Help Customers understand the need to accumulate assets for Later Life

– Engage at outset

– Communicate progress and implications

Focus Not just on High Net Worth but also on “average” customers

Deliver simple, high quality, low cost accumulation vehicles

– ISA

– Pension

Manage Care Longevity Risk

– Provide guaranteed annuity products

– Innovate to combine with Retirement pension products

Dr. Ros AltmannSAGA

Private and confidential: not for onward distribution DRAFT / ISSUE x.x

Future of Care FundingRole of the Private Sector

ILC-Actuarial Profession Conference

18th October 2011

Presentation byDr. Ros Altmann, Director-General, The Saga Group

Twitter: @SagaRosAltmann

Care in Crisis

Worse than pensions crisis as population ages and care needs rise

No money set aside privately, not enough publicly

Can’t just tell people to wait longer!

No integration of Care with NHS – no incentives to save money on NHS

Local authorities cutting spend from already inadequate levels– No ring-fencing of new money

NHS is the most expensive option – and the safety net!– NHS will run out of resources

What’s gone wrong – funding of care?

Policymakers focus later-life income on only pensions

No private pre-funding for care (and billions in pensions is not enough)– No savings incentives for care

Insurance can’t deliver unlimited costs cover

Public funding falling as demand rises– New money not being ring-fenced

Stark means test: £23,250 – many use all their assets and fall back on state

Vital elements to improve care funding - Challenge to Government

Information and education – only 7% of self-funders get proper advice

Tax incentives for care saving plans – workplace incentives?– Care ISAs– Care Annuities– Insurance (pricing?)– Family Care Plans

Equity release

Using the home

A house could be considered precautionary savings or insurance policy

Asset is there, but not for care! - political problem

1 in 4 over 55s still has a mortgage, – Average mortgage £61,000, average house value £231,000– But would people then be slower to repay their mortgage?

Local authority deferred payment plans

Insurance

Immediate needs annuities – only 8,000 a year

Standard annuities provide regular income but won’t cover high care costs

Long-term care insurance is a market failure

Pooling risk makes sense

Developing insurance could improve prevention – e.g. burglar alarms, locks for house insurance

Conclusions

Two big challenges: – Delivery of care efficiently and cost-effectively– Funding care adequately in advance, not at point of need

Partnership approach makes sense

Role of private sector to help pre-funding

Will it encourage new products for care? Not on its own

You can argue with the detail but reform is essential – avoid long grass!!

Where Next for Care?Concluding Thoughts

Baroness Sally GreengrossILC-UK

Where Next for Care?

18 October 2011

'Where next for care?' ILC-UK and the Actuarial Profession Day Conference supported by Partnership

funding of care

costs of care

supportsocial care

free care

residential care costs5

public funding forthe

fairer care fundingconclusions

older peoples social

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