Yes, no, maybe... where do you stand on the top 12 arguments in adult social care?

1. Should there be different social care systems for working age adults and older people?

Yes

Older people have different needs and want different outcomes. It’s sensible and pragmatic to acknowledge this by having different systems of eligibility, assessment and service provision, as they do in countries like Australia.

No

The underlying principles and ethos of social care is the same: supporting people to achieve the outcomes they want. Chronological age is a poor basis for deciding the support someone might need and treating people differently because of their age is discriminatory. Separate systems would also create a ‘cliff edge’ between one system and the other.

Maybe

Life stage does influence what people want and need from social care. An 18-year-old with a mild learning disability will want different support to a 98-year-old at end of life. But age doesn’t determine everything: some 18-year-olds will need nursing support; some 98-year-olds will want help to remain active and independent. A good system needs to be able to accommodate both.

2. Should local government retain its current, dominant role in social care?

Yes

Local authorities are best placed to ensure that social care support is embedded in communities, tailored to the needs of local populations, and coordinated with health, housing and other critical services. This will mean some differences between the types of services and support in different areas. This is about ‘postcode choice’ rather than ‘postcode lottery’.

No

Local assessment and delivery means there are 153 social care systems with wide, unfair variation in people’s access to state-funded services, and in the fees paid to providers. We need strong, national assessment and delivery of social care with clear, legally-binding minimum rates for providers and terms and conditions for staff.

Maybe

Local authorities are essential to social care but some functions of local government, such as assessment, might be more effectively carried out nationally, as happens in other countries. A stronger national standards framework for social care is also needed to ensure support is consistent. National funding for social care would also help even out the inconsistencies between local authorities in their ability to raise money to spend on care.

3. Should we adopt an NHS-style system in which everyone is entitled to ‘free’ social care?

Yes

It is the fairest, simplest system and it’s what we should have introduced in 1948. It fully pools the cost of care risks that people face. It’s the only way to ensure full integration with the NHS. It’s affordable – we are still a wealthy society.

No

It is not affordable at the moment and never will be. Our current system rightly focuses state support on people with the highest needs and lowest assets. Social care for older people is not the same as health care generally: we know we will get old so we should take some responsibility for planning for care needs that may arise.

Maybe

The current system is unfair: the state does need to take more responsibility for funding people’s care costs. But people should contribute if they can, and there are other systems that offer universal – or at least much wider – access without the expense of an NHS-style system.

4. Should we have more not-for-profit and fewer for-profit services?

Yes

There is no place for profit in the caring services. Profit-making, particularly by private equity companies, leaks money out of social care that otherwise would be available to improve services.

No

There is very limited evidence that not-for-profit or public sector services are better quality than for-profit ones. Public sector delivery is more expensive than for-profit services. For-profit services are the ones investing in new services.

Maybe

While there’s no realistic possibility of a market without for-profit providers, there is scope for more regulation and transparency of provision to ensure ‘fair’ profits as part of an ‘ethical approach’ to commissioning.

5. Do low fees put many providers at risk of going out of business?

Yes

Low fees and increasing costs, particularly for staff, have pushed providers to the brink. The rise in employers' national insurance is the last straw for many. Local authorities consistently report too many providers handing back contracts or going out of business. Others will have to strip back services because of insufficient fees.

No

As costs have risen over time, providers have been quite successful at winning increased fees from local authorities. Most continue to make surpluses that can accommodate increased costs. There is no sign of major market failure.

Maybe

Increasing costs will have a real impact in the marketplace but for most providers it will involve cutbacks in investment and changes to business strategy – for example, focusing more on the self-funder market. However, providers who can’t adapt, or are in sectors where they cannot rely on cross-subsidisation by self-funders, will be at risk.

6. Is more funding the most important factor in improving social care?

Yes

Increased funding would ensure that everyone who is currently entitled to support gets it and their needs are fully met. It would ensure that providers can provide quality services and staff are fairly paid. No significant change can happen without more money.

No

The key issue isn’t funding – it’s culture. Too much money is wasted on complex systems and bureaucratic controls. Power structures in commissioning and provision mean that people who draw on services have too little choice and control. Spending more money in the same way won’t change very much.

Maybe

Some improvements cost little to implement, but require cultural change which is hard to achieve in practice. Other changes, such as increased eligibility to publicly funded care, inevitably come with a clear price tag. Who gets to have a say in how any extra money is spent may be key.

7. Is it more important to loosen the needs test than the means test?

Yes

Many people have relatively low or moderate needs that could and should be addressed by adult social care. This extra support would allow more people to live more independent lives but also help prevent needs from escalating and limit usage of other public services like the NHS. This is far more important than supporting people on higher levels of income and assets, who can afford to pay for their care from savings or housing wealth.

No

The system in England means that people with moderate assets are prevented from receiving any public support with their care costs, even when these ultimately run into hundreds of thousands of pounds. Polls show that many people see this as a gross unfairness that needs to be tackled as the number one priority.

Maybe

There is a strong case for supporting more people with lower needs, as part of building a preventive health and care system. However, we have a particularly ungenerous means test that also needs tackling because of its unfairness. This may also help drive up quality: focusing all resource on people with the lowest assets creates a risk that social care is simply a ‘poor service for poor people’.

8. Is a social movement the only way to bring change in social care?

Yes

All previous attempts to bring about change through national politics have failed. Change will only happen when the public understands and supports a positive vision of what social care offers to society and creates the pressure for local and national political change.

No

It’s not possible to build a mass social movement for services that are used by only a small fraction of the population and which most people don’t prioritise as an issue. It is better to focus on building the political and economic arguments for change.

Maybe

Wider public support, informed political support and stronger economic arguments are all needed. Together they create the most likely circumstances for adult social care reform.

9. Do we need to stop talking about a ‘crisis’ to win support for social care?

Yes

The language of persistent crisis turns people off: they think nothing can be done about social care. The language of ‘vulnerable service users in need’ is at odds with a positive vision of social care offering the right to empowering support that enhances wellbeing.

No

Campaigning has successfully won vital extra money from governments over the last decade. Without it, social care would be in much worse shape. We have to bring home the problems to get people’s attention and we have to use hard-hitting language to hold it.

Maybe

We need to call out the problems faced but balance that with a positive view of what social care offers people. We need to tailor our messages for different audiences, using language that people understand but avoiding words and phrases that offend.

10. Is workforce pay the number one priority in social care?

Yes

Low pay results in high levels of vacancies, which make it impossible to provide the quality and consistency of social care support that people need. It is also morally wrong that care workers do difficult jobs for such low pay.

No

Low pay is only one of several critical issues facing social care, not all of which are linked to vacancy levels, which are now lower than they were before Covid-19. It's more important to fund more packages of support for more people.

Maybe

Higher pay will be a critical factor in attracting more staff to social care. However, it will have to compete for funding with other issues such as improving eligibility for care and must be introduced in a way that maintains the stability of providers.

11. Should all social care staff be registered?

Yes

Registration of social care staff would improve safeguarding, ensure minimum qualifications and training, and bolster the image of social care to the public.

No

A register requiring qualifications would put off some people from working in social care when it is already difficult to recruit staff. Holders of direct payments shouldn’t be restricted in who they can hire as personal assistants.

Maybe

Registration might be better introduced once funding is more assured and progress has been made on other factors like pay and training. It should be light touch and some roles, such as personal assistants, should be excluded.

12. Are there too many providers in the market?

Yes

Over 18,000, typically very small providers is too many to be efficient and for effective regulation. Too many providers enter the market without adequate checks on their stability or quality, sometimes encouraged by local authorities because they offer low rates. Personal assistants are unregulated, which is a risk to people using services.

No

The full range of providers is essential to ensuring that people have the choice they want. Often, smaller, niche providers offer the particular services that people are looking for. In some markets, smaller micro-providers are essential because there are care deserts where larger providers don’t venture. Personal assistants are critical to people who use direct payments in particular.

Maybe

There has to be a medium between a proliferation of smaller providers that are difficult to regulate and lack stability, and a market of only larger corporates that don’t meet the needs of all the people who need services. It’s the job of local authorities with their market shaping powers to find that happy medium.