Einstein said that everything should be made as simple as possible, but no simpler. He would surely turn in his grave at the state of the debate about social care reform in England which, increasingly, has been reduced to whether the government will introduce a 'cap' on social care costs and, if so, how it will pay for it.
This fails to acknowledge that a cap is only one of several different ways of setting the level of overall access to publicly funded social care. These approaches are not mutually exclusive: most countries, including England, use a combination of approaches so a cap on costs needs to be seen as just one of several ways to make access to social care fairer and more equitable. It is a refinement to the current system, not a replacement of it.
Which approaches do countries use to set the level of access to social care? Broadly, there are four: free access, a means test, subsidy and a cap on costs.
Most countries have at least some services that are free to those who need them. The European Commission notes that Denmark has 'perhaps the most universal LTC [long-term care] system in the world’,' financed through general taxation and generally provided free of charge’. It is similar in many ways to the NHS in England. But you don't need to go as far as Denmark to find universal services: in Scotland, people have been entitled to free personal care at home since 2002. Not so in England however: here, free services are limited to basic services such as advice and information, and to short-term services such as reablement.
'In England, most formal services are also means tested – if you have more than £23,250 in assets and need a care home, you will pay for it yourself.'
Universal services are, of course, expensive, so many countries, including England, have chosen to use a means test to restrict many of their social care services. The United States, for example, has tight restrictions on access to long-term care, with only people with the lowest assets being entitled to Medicaid. In England, most formal services are also means tested – if you have more than £23,250 in assets and need a care home, you will pay for it yourself. Access to universal services is again limited to those with the lowest assets.
Another way to moderate costs of publicly funded social care is when the state offers subsidy towards the cost of social care but doesn’t meet it in full: typically, people are required to contribute co-payments towards their care. This applies in Germany, where there is universal access but people contribute on average nearly £770 a month towards their residential care costs. Japan is similar but more generous (for older people at least): home care, day care, short-stay care and residential care are available to all older people but service users must pay a co-payment of up to 30 per cent. England also uses co-payments: service users are frequently required to contribute from their income towards the cost of their care and indeed many councils have helped make ends meet in recent years by raising charges on service users.
Finally, there’s the cap. You will find examples of it in Wales, where for people with the lowest assets receive free home care but others pay the full cost to a maximum of £100 a week. It also applies in Australia, where the cost of residential care for older people is capped annually at around £15,000 and over a lifetime at around £36,000. Japan too has a monthly cap on residential care costs and Germany has now also moved to introduce a variable cap.
'The extent to which people are offered free social care services, and the degree to which they are restricted by a means test and co-charging, also have to be considered as part of funding reform.'
The critical lesson for the debate about reform in England is that the introduction of a cap – and its level – is only one of several factors that will determine whether England moves towards a fairer, more equitable social care system. The extent to which people are offered free social care services, and the degree to which they are restricted by a means test and co-charging, also have to be considered as part of funding reform. The original Dilnot proposals recognised this and recommended not just a cap but also reform to make the current means test more generous.
That is the very least that is needed when the government announces its proposals later this year. There needs to be a simpler and fairer social care system based on the principle of ‘risk pooling’ – money raised from the population as a whole should fund the cost of those people who need social care. The government has promised to ‘fix’ social care and this is the basis for doing it.