There is general agreement that the success story of our ageing population comes at a price. We face the prospect of devoting a larger proportion of our national wealth to paying for good health and social care that more of us will need.
But agreement about how this should be done has been elusive despite the best efforts of numerous independent reviews, commissions, White Papers and Green Papers over the past two decades. England remains one of the few advanced western countries that has not grasped the nettle of reform, and recently there have been calls for another independent commission with all-party support.
So it is timely to consider the latest evidence from the British Social Attitudes survey, conducted by NatCen Social Research, about what the general public thinks. In the 2015 survey, The King’s Fund sponsored a question about how social care, to meet needs arising from illness, disability or old age, should be paid for. More than 1,000 adults were interviewed between July and October last year and their responses were weighted to correct for non-response, and to match the British population in terms of age, sex and region.
Of those interviewed, almost half – 48 per cent – believe that the government should meet the costs of care through taxation (see figure). This chimes with the recommendations of most independent reviews which favoured public funding rather than private options (such as insurance or user charges). But there is equal support for individuals contributing from their own resources: 25 per cent thought that the individual should pay what they can with the government paying the rest. And another 22 per cent supported this – but with the proviso that no one should have to pay more than £72,000 in their lifetime (this being the amount that would have been ‘capped’ by the Care Act reforms that the government has postponed until 2020).
Views do not vary significantly by age – no intergenerational split here – but unsurprisingly Labour supporters have a stronger preference for fully tax-funded social care (56 per cent) than Conservatives (31 per cent).
There are caveats. A single question cannot capture the range and permutation of potential funding options. For example, taxation could be general or specific, direct or indirect, taxation of income and/or property and wealth – each option eliciting different degrees of political and public attractiveness – or hostility. As well it could be argued that most people would choose better public services that are important to them as long as someone else pays for it. And while there is no country in the world that meets all the costs of care through the public purse, there is no country that allows all of the costs to fall on the shoulders of the individual and family either (though England is getting close). It is the mixture and balance of funding mechanisms and sources that is key.
The BSA findings reflect different views about the balance between state and individual contributions, with a fairly even split between those favouring taxation to meet the whole cost and those supporting an individual contribution if they can afford it. But it is important to note that respondents are drawn from the general public and may not necessarily have experienced how the care system currently works – namely that anyone with more than £23,250 in savings and assets (including the value of their house) is expected to pay for the full costs of their care (those with less than that get help only if they have very high needs). Currently 50 per cent of care home fees are met by individuals themselves, involving significant top-up payments from family members. Co-payment on this scale for NHS services would be greeted with public and political outrage. If respondents had been aware of just how much of the care cost burden falls on the individual, might support for wholly public-funded solutions have been higher still?
The consequences of last year’s Spending Review and local government financial settlement will see the share of GDP devoted to public spending on social care fall by the end of this parliament. By default this will shift more of the funding burden on to private individuals. The contrast, identified by the Barker Commission, with NHS funding and entitlements – free at the point of use, used by most of the population and funded largely through general taxation – is set to become starker still. It is unclear whether many people grasp these fundamental differences but public opinion is clearly at odds with the direction of government policy on how social care is funded. The need for a serious debate with the public about these differences and where the money to fund social care will come from has never been more urgent.