Background
Social care covers a vast array of services designed to help vulnerable people to maintain their independence. It will usually be needed because of old age, learning and physical disability, accident, long-term illness or mental illness. It is staffed by the biggest workforce in the country, numbering around 1.5 million people working for an estimated 39,000 different organisations. In addition, the system depends heavily on the unpaid work of around 6 milliion informal carers.
A complex area, social care is not well understood and has for many years been the poor relation to health care, mainly because while NHS care is funded by the taxpayer and is free to all, much social care is only available on a means-tested basis. The result is that many whose needs do not fit closely defined health criteria and who have assets above a certain level have to pay for their own care or may go without help.
There have been intermittent attempts to resolve the perceived unfairness of this divide between health and social care. A Royal Commission into long-term care in 1999 recommended that personal and nursing care in care homes should be free as should ‘personal care’ – help with such things as dressing, feeding, washing and toileting – within the home. It also proposed that health and social care budgets be merged.
The proposals were rejected by the then government because of the prohibitive expense (estimated to be around £1.1 billion a year rising to £6.4 billion by 2050). But since then – and despite big increases in social services budgets – the funding gap between health and social care has widened, as has the shortfall between the demand for social care and councils’ ability to provide services.
The gap is predicted to get much worse. Projections suggest that the number of people over 85 will rise by two thirds by 2025 with a concomitant rise in chronic health and social needs. Meanwhile, a Foresight report last year warned the number of people with dementia could double in the next 30 years and the costs to the economy triple from £17 billion to £50 billion a year.
The result is that councils increasingly ration social care services. CSCI (the Commission for Social Care Inspection) calculated last year that two-thirds of councils were offering care only to those users considered to have ‘critical’ or ‘substantial’ needs – and the proportion in that category was growing. Many also experience a ‘postcode lottery’ not only because of the disparity of services offered by different councils but because councils’ criteria are being interpreted differently in different areas.
A number of reforms of social care have take place over the last decade. In 2005 adult and children’s services were split, with children’s services becoming integrated with education. Most councils have combined adult social care with other services such as housing and leisure. A Green Paper in the same year promised wide-ranging reform of adult services, including greater emphasis on independence, well-being and choice, individual budgets and universal access to a ‘care navigator’ who would offer advice and information on available services.
In December 2007 the Putting People First concordat promised a bigger role for councils and the creation of a personalised service, allowing users more independence and greater choice and control over their care. One of the main mechanisms for delivery of this are personal budgets – an amount of funding allocated to a user that allows them to control which services that funding is used to purchase; the Labour government pledged £520 million to ensure most users can personalise their care by 2011.
This has been backed by a range of initiatives to improve the care of often neglected groups. Valuing People in 2001 promised a new deal for people with learning disabilities and set a 2025 deadline for achieving full equality. The first National Carers’ Strategy was unveiled in 1998 and was revamped and expanded last year. A campaign was launched to promote dignity and respect in the care of elderly people. And in 2009 the Labour government launched its first National Dementia Strategy.
There are also moves to co-ordinate health and social care planning, aided by most primary care trusts and local authorities now covering the same geographical areas. The inspection regime has also been brought together with the merger of the Healthcare Commission, CSCI and the Mental Health Act Commission into the new Care Quality Commission, which started work on 1 April 2009.
But there is only so much that can be done as long as the funding arrangements for social care remain unaltered. A major review of social care for older people by Sir Derek Wanless for The King’s Fund in 2006 suggested the system needed to be radically overhauled. One of the principal reasons was the huge predicted growth in the very elderly with increasing health and social care needs. He proposed a ‘partnership’ funding model in which everyone would be guaranteed a basic level of care that they could then choose to top up. The overall extra cost would be around £1.7 billion a year.
Those ideas fed into the previous government’s announcement in 2008 of a ‘once in a generation’ review of how social care is organised and funded. A Green Paper on the future of social care was unveiled on 14 July 2009 and a White Paper followed on 30 March 2010.
The coalition government has pledged to consider the recommendations of the Law Commission and the Dilnot Commission, alongside its previously published Vision for Adult Social Care. It intends to publish a White Paper on social care reform in December 2011 followed by legislation in the next parliamentary session.
