Skip to content

Reform of adult social care: some progress, but nowhere near enough


In November 2019, we identified the eight key problems in adult social care that any reform would need to address. Since then, the government has issued four key documents outlining measures that directly affect adult social care: its Build back better plan for health and social care, the People at the heart of care social care White Paper, the Health and Care Act (which has now received Royal Assent) and a White Paper on integration of health and care. Together, these introduce major reform to adult social care, with measures including further integration with health care, changes to the means test for social care, a cap on social care costs and an intervention in the social care market intended to ensure local authorities pay a ‘fair price’ for care. But are they enough to tackle the eight deep-rooted problems in the sector? Here’s our assessment.

Overall, the government has gone further than previous administrations with its reform of the means test and introduction of a cap on social care costs. However, the small print behind the cap leaves a bitter taste in the mouth. Elsewhere reforms are either smaller scale or it is too early to judge their impact. Finally, there is almost total failure to address the twin issues of wider unmet need and the workforce, problems identified by the public in the recent British Social Attitudes survey.

Worryingly, all these changes are happening to a system that already faces intense underlying pressure from increasing demographic demand, the continuing impact of the Covid-19 pandemic, soaring inflation and levels of funding that have only just surpassed in real terms those of a decade ago. Together, this means that – sadly – there is still a very long way before England has an adult social care system that is truly fit for purpose.

What's the problem?What has the government done?How effective is that response?What's the score?
Means testingThere is a means test that restricts access to adult social care services.The Minimum Income Guarantee (MIG) rose by 3.1 per cent in April 2022. The means test will be more generous from 2023 (upper threshold: £100,000, lower threshold  £20,000).Good. More than 40–50,000 more people will be able to access state-funded care each year, after a decade in which the means test became tighter in real terms. However, the changes to the MIG are very limited and, overall, social care remains much less accessible than a free-at-point-of-use NHS.7/10
Catastrophic costsMany people who pay for their own care spend more than £100,000 over their lifetime.There will be a cap of £86,000 on lifetime care costs from 2023.Disappointing. The cap is much less generous than expected. It is too high and, those with assets of less than £106,000 will get very little benefit.5/10
Unmet needAround 1.6 million older people and an unknown number of working-age adults don’t get the support they need. Relatively few of the estimated 4.5 million unpaid family carers in England receive local authority support.The changes to the means test (see above) will bring more people into the state system.Very limited. More than 40–50,000 people each year will benefit from the changed means test, but people also need to pass a very strict needs test to access publicly funded care. The needs test has, in practice, been getting stricter over the years as local authority budgets struggle to keep pace with increased demand. Only £25 million has been earmarked to ‘kickstart a change in services’ for carers’.2/10
Quality of careThere is public concern about quality of care,  ranging from 15-minute home care visits and extending to fears of abuse and neglect in care homes.There are low-key plans to improve innovation, care and support planning, and digital connectivity. There are also plans to integrate housing into health and care strategies and measures to address the postcode lottery (see below).Limited. There are no measures to improve users’ choice and control of publicly funded care services. Quality of (as well as access to) services is also affected by difficulties in recruiting staff (see below). The funding for these plans adds up to only extra £550  million over three years (£300 million of which is for housing), compared with £26 billion spent every year on publicly funded adult social care.4/10
Postcode lotteryAccess to social care varies depending on where people live and, while some of this variation is a response to differing needs, some is not.The Health and Care Act gives the Care Quality Commission powers to audit local authorities’ delivery of adult social care.Potentially valuable. It is a welcome move but it is not yet clear which aspects of local authority delivery will be included.Too soon to say, dependent on details yet to be announced.
WorkforceThere aren’t enough staff in adult social care and most observers believe better pay is the critical factor in recruiting more.The reforms provide £500 million over 3 years for workforce wellbeing and training, and there has been short-term funding to support recruitment.Severely limited. There is no long-term solution to workforce issues. The government’s impact assessment on its reform included workforce but failed to mention pay.2/10
Market fragilitySome social care providers hand back contracts or go out of business because the rates paid by local authorities for care are too low.The government will provide financial support to local authorities to carry out ‘fair cost of care’ reviews, which will result in a ‘move towards’ paying higher fees. The aim is to end the situation in which people who self-fund pay more than people who are publicly funded.Very unpredictable. ‘Fair cost of care’ is a major intervention in a failing market but local authorities and providers fear there will not be enough financial support and it may even undermine the provider market further.Too soon to say, still highly uncertain.
Disjointed careDifferent parts of the health and care system are not working together to deliver care effectively.By July 2022, England will have 42 integrated care systems tasked with joining up health, care and other services.Potentially important. The ambition to plan and deliver joined-up services to improve the health and wellbeing of local people is a critical one. However, there are fears that underfunded social care will lack influence over NHS-dominated structures.6/10 (depends on how each ICS implements reforms).