What’s your problem, social care? The eight key areas for reform

The Prime Minister, Boris Johnson, has promised to ‘fix’ social care. But what exactly is he is trying to fix? And for whom?

Different people have different ideas about what is ‘wrong’ with social care and how to fix it. The problems boil down to eight issues, consistently identified by service users, carers and families, policy-makers and people working in the sector.

For all these there is an added dimension: ‘for how long?’ With demographic changes – an ageing population and more working-age adults living with complex disabilities – any view of the problem and the fixes must look not only to today but decades ahead.

There are also obvious questions about how to fund reform, and we need to accept that there are underlying tensions and choices – no reform will deliver everything that everyone wants.

But these can be navigated if, despite the problems, we retain a positive vision of social care as a solution, supporting people to live the lives they want and be actively involved in their communities and wider society.

1. Means testing: it's not like the NHS

What’s the issue?

Many people believe that social care, like the NHS, is free to those who need it but in fact it is only provided free to people with low assets and savings (and even then only if they have needs above a defined level). Everyone with assets of more than £23,250 must pay for themselves, rely on family, or go without. The funding of the NHS, by contrast, involves ‘risk pooling’ – everyone contributes to total costs through taxation and people receive the amount of care they need, however expensive that is. This distinction is at the heart of claims that people who have cancer will get the treatment they need for free from the NHS while those with dementia must pay for it.

Which options are cited to tackle it?

An NHS-style funding system. This option would make all social care free to those who need it, irrespective of income and savings (similar to the way the NHS works). However, this would be very expensive: as a crude guide, the National Audit Office estimates that people already privately spend around £10.9 billion a year on care, but offering free care for all would generate even more demand than this and therefore cost even more

Free personal care. In this option, only some types of social care would be free – for example, help with washing and dressing. This is the system that operates in Scotland and would cost around £7 billion to introduce in England. However, it excludes much social care, including support for lower-level needs (so-called ‘mopping and shopping’ services), wider support in the community and accommodation costs in care homes (in Scotland, people get just £177 a week towards costs but average bills are more than £600).

Making the means test more generous. This could be achieved by raising the point at which people have to pay for their own care from £23,250 (a figure that hasn’t changed since 2010) to a much higher figure. The Dilnot Commission on Care and Support recommended in 2011 this should be £100,000, while the government prepared legislation that would have raised it for residential care to £118,000 in 2016. In Wales the figure is already £50,000 for people in care homes.

2. Catastrophic costs: selling homes to pay for care

What’s the issue?

Because many people have to pay for their own social care (see means testing), some people with significant care and support needs (the Dilnot Commission estimated 10 per cent of those over 65 years old) will end up paying very large sums – £100,000 and above. Many will have to sell their main asset – their home – to pay these costs. This has been a key focus of concern for many politicians, from Tony Blair to Boris Johnson.

Which options are cited to prevent it, and would they work?

An NHS-type social care system (see means testing). This system would pay all care costs but would be very expensive.

A cap on an individual’s care costs. This would keep the means test but people would ‘log’ how much they spend on eligible care costs and once they reach a certain point (a ‘cap’), the state would take over payment. The Commission on Care and Support in 2011 recommended this cap should be set at £25–50,000 and in 2013 the government proposed, but did not implement, a cap of £72,000. A cap might be a complicated system to administer – though this could apply to other solutions too – and some people would still need to spend a lot of money as not all care expenditure would count towards the cap.

Deferred payment agreements. These allow people who own a home to put off their care costs until they die. They don’t prevent catastrophic costs, just delay them until someone dies and their house is sold. Local authorities are supposed to offer deferred payment agreements to people who might benefit but take up is patchy.

Private insurance. These are policies that people take out to protect themselves against care costs – either a one-off payment on entering a care home or a regular payment starting when relatively young (long-term care insurance). Only a minority of people take these up, however, and there is little international evidence that long-term insurance schemes are an effective solution to long-term care costs for many people.

3. Unmet need: 'people going without care and support'

What’s the issue?

Means testing creates one form of unmet need by limiting publicly funded social care to people with the lowest assets. But others are excluded from public support because their condition (or ‘need’) isn’t considered serious enough for them to be entitled to publicly funded support. A further source of unmet need is people who aren’t aware they might be entitled to support or don’t come forward. Unmet need is not just a ‘moral’ issue but one of effectiveness; support for lower-level need may help prevent people’s conditions deteriorating – and avoid putting unrealistic expectations on family carers. There is no agreement about the overall level of unmet need (partly because it depends on what you think people should be entitled to) but Age UK has a widely-quoted figure of 1.4 million older people who are not getting the care and support they need.

Which options are cited to meet it, and would they work?

Make the means test more generous. This would bring more people into the publicly funded system, though it wouldn’t expand support to those with lower levels of need.

Reduce the level of need required to receive publicly funded social care. Currently – following years of reductions that started well before ‘austerity’ – people only receive support if they have needs that are, in effect, classified as ‘substantial’ or ‘critical’. This could be reduced to include needs classified as ‘moderate’ or some services could become universal (after all, who – except someone who really needs it – would want a ‘free’ grab rail in their bathroom?). Others argue that all needs preventing someone from living an independent life should be met.

Improve advice. More people could be made aware of their entitlement through information and advice, and by providing advocacy support to those who need it. This would help ensure that people who are already entitled to support actually receive it.

4. Quality of care: 15-minute care visits and neglect

What’s the issue?

The term ‘quality’ covers a wide range of perceived issues. There is basic concern among the public about quality, illustrated by 15-minute care visits in home care but extending to fears of abuse and neglect in care homes. Some focus on the consequences of having an unregistered and undertrained care workforce. Others question the model of delivery itself, particularly a reliance on institutional care and a perceived lack of choice and control for service users. It is also worth noting that measures of quality such as Care Quality Commission ratings and satisfaction surveys among service users do not suggest any major recent decline in quality.

Which options are cited to improve it, and would they work?

Commission for quality not price. Local authorities’ approaches to commissioning care services have typically been driven by a desire to minimise costs. Yet, though the effects are hard to prove, this seems likely to drive down quality. One way to change this would be for local authorities to pay more: industry bodies, for example, recommend setting minimum payment rates for home care and residential care. This would require not just more money but might also require more local commissioning expertise.

Better regulation, monitoring and support. This would focus on improving the effectiveness of regulators as a route to better quality, though to be effective it would require additional practical support for providers that are struggling (as, for example, is provided by NHS England to GP practices). Some local authorities already bring together and support care home managers in a bid to drive up quality.

Improving information for purchasers. Though social care is mainly provided by competing private sector organisations in a free market, it is not a market in which it is easy for people to make informed choices, especially when these choices are often made at times of crisis. Improving information about the quality and cost of care on offer and making it easier for people to raise concerns about services they are receiving might improve quality.

Workforce development. See workforce pay and conditions.

Personal budgets. A key direction of recent reform has been to give service users their own budgets to spend, partly to give them greater flexibility and partly to develop a more effective market for service providers. For some people this approach is life changing but evidence is unclear about outcomes and personal budgets have not spread as widely as hoped, especially among older people.

Wider reforms. For some, the way we commission and provide social care services needs to change more fundamentally. Typically, this involves a move away from institutionalised, professionalised care towards much broader forms of support, exemplified by services such as the Shared Lives scheme and other strength-or asset-based approaches. Again, however, these models may work better for some people, for example, working-age adults with learning disabilities, than others.

5. Workforce pay and conditions: underpaid, overworked staff

What’s the issue?

There aren’t enough staff in adult social care – there are 122,000 vacancies at any one time. Most observers believe that better pay is the critical factor in recruiting more: though pay has risen as a result of the National Living Wage, care workers are paid on average less than cleaners, shop assistants and health care assistants in the NHS. Conditions of employment are also a factor, with more than half of home care workers employed on zero-hours contracts. Staff often don’t get the training and support they need to carry out complex, difficult tasks for vulnerable adults and they lack a career structure – care workers with five or more years’ experience are now paid on average only £0.15 an hour more than new entrants.

Which options are cited to improve it, and would they work?

Better basic pay. Increasing basic pay is vital, and pay differentials between junior and senior staff need to widen. This is difficult to achieve uniformly though because care workers are employed by around 20,000 independent organisations and, unlike the NHS, don’t have national pay rates. Nor can all these providers afford to pay more, since the fees they receive from local authorities have been held down.

Developing workforce strategies. There is a clear logic to social care and NHS providers developing joint workforce plans. However, there are few examples of these. Some strategies specific to social care are being tried, for example, in Somerset, where people are encouraged to set up as self-employed providers of services, aiming to increase the workforce and its flexibility. And there is already a market for around 145,000 personal assistants in social care, employed directly by care users holding personal budgets from their council.

Regulation/registration and training. In Scotland, Northern Ireland and now Wales, registration schemes require care workers to reach a minimum level of skill or qualification. The cost-effectiveness of these approaches isn’t clear though, and there is a risk that some workers may be deterred from joining or staying in the sector. However, more training clearly needs to be available to the care workforce, either directly or through their employers, since they are caring for people with complex conditions. That in turns requires money.

Bringing it into the public sector. The most radical approach to workforce is to bring some or even most of the social care workforce into the public sector, as the Labour party has proposed. This would lead to improved terms and conditions for staff, but beyond this it is not clear what additional benefits it would bring to people needing care. Nor is it what service users (including those who pay for their own care at the moment) necessarily want. This would also have to be funded.

Expanding the pool of potential staff. Non-UK workers play a vital role in social care, making up 17 per cent of the workforce, almost evenly split between EU countries (other than the United Kingdom) and non-EU staff. As the United Kingdom exits the European Union, it will remain important to find a route into social care for non-UK staff, whether from Europe or elsewhere. In addition, while pay is clearly an issue, more needs to be done to make social care an attractive career for UK workers: 1 in 5 considers a job in the sector but only 1 in 25 of these applies for one.

6. Market fragility: care providers going out of business

What’s the issue?

Most social care services are commissioned by local authorities but delivered by thousands of mainly private companies. This market has been in trouble for some time. Local authorities have been trying to limit how much they pay for services but providers have been hit by increasing costs, especially for staff as a result of the minimum wage. The result is increasing numbers of providers going out of business or handing back contracts. In addition, some providers are focusing on services for people who fund their own care, who will pay more. This can cause supply problems: one estimate suggests the UK needs capital investment in 75,000 new care home beds by 2030 but this is more likely to happen in wealthier areas with lots of self-funders than in deprived ones.

Which options are cited to strengthen it, and would they work?

Paying more. If local authorities paid providers more for care, it should help them survive, improve quality and – at least in theory – mean better pay for staff, which would in turn reduce workforce pressures. Appropriate fee levels should also allow for return on investment for much needed capital improvements to be made. Providers who have focused purely on self-funders might also return to publicly funded care, increasing capacity. Of course, it would require more money.

Bringing services in-house. Some, including the Labour Party, argue that bringing more provision of social care into the public sector, either by nationalising providers or by local authorities employing care staff directly, would resolve market problems and be more ethical. Some local authorities are considering elements of this, often to resolve local supply problems. This could be difficult to put into practice, though, and most likely increase costs because in-house provision typically costs local authorities more than buying it.

Market shaping. Local authorities have a duty to ‘shape the market’ for care provision in their areas but, in practice, few have taken this role as broadly as it was intended. However, they could – and some now are – take a more active role to support and develop local care providers, commission with broader, ‘social value’ objectives and sometimes step in to provide services where the market cannot. Again, though, this would come at a price and requires strong planning, commissioning and management expertise.

7. Disjointed care: delayed transfers of care and lack of integration with health

What’s the issue?

People too often receive fragmented care, which can have a negative effect on their experiences, lead to poorer outcomes and create inefficiency within health and care. Yet efforts to join up the systems have been held back by the fundamental cultural and structural differences between the two, which go back to the establishment of a free NHS and a means-tested social care system in 1948. The problem is routinely exemplified by patients stuck in hospital while they await social care services but it can also mean people discharged too early into the wrong sort of care, or under-investment in preventive services like re-ablement. The boundary between the two systems is also riddled with complexity and controversy, exemplified by NHS Continuing Healthcare where, if someone is assessed as having a ‘primary health need’, the NHS will pay their social care costs.

What options are cited to join it up, and would they work?

Narrowing the eligibility gap between the systems. Giving more people access to free social care, similar to the NHS, would reduce one difference between the two systems, with the potential to create faster and more efficient interchanges between the two. The Barker Commission, for example, proposed making all care free to those with the highest needs. However, simply widening eligibility is not a panacea to all problems and will inevitably cost money.

Integration. Integrated care systems (ICSs) aim to tackle the underlying issues that prevent improved working together. Yet there is ambivalence (sometimes on both sides) about whether local authorities are full partners in these systems or simply a stakeholder. And pressures to tackle urgent issues – like delayed transfers of care – can lead to tension between system partners. Structures like ICSs also depend on the relationships between people working in the two systems to be effective (though this may apply to any system or structure). However, they can take a long time to show impact and can be set back when individuals change roles.

Technology. Many approaches to integration require health and social care systems to communicate more effectively through technological advances like joint care records or giving care homes access to NHS email. These can sometimes have groundbreaking results but can be slow to implement and, as with structure, do not in themselves create more integrated care. And there is a danger that a better-funded NHS runs ahead of a highly diverse and under-resourced social care sector.

Personal budgets. Giving people individual budgets to spend on their combined health and care needs aims to help the individual integrate services around themselves. While personal budgets have the potential to be life changing for some people, there are doubts about how far they can be extended: the experience in social care suggests limited appetite for them among many older people, for example.

8. The postcode lottery: unwarranted variation in access and performance

What’s the issue?

Though the rules on entitlement to publicly funded social care are set nationally, access to social care varies depending on where people live. Unlike the NHS, each local authority makes its own decisions about budgets and services, so some spend more per head and/or provide more short- or long-term support than others. The reasons for these differences can be hard to explain. Some variation may be reasonable responses to local circumstances – [postcode choice](https://www.local.gov.uk/sites/default/files/documents/3_july_22.24 LGA think piece series the care and support green paper_v03_0.pdf) rather than postcode lottery – and can reflect the different amounts of money local authorities get from government and Council Tax. This may affect the amount and quality of care providers available, not just for publicly funded care users but self-funders too.

Which options are cited to even it out, and would they work?

Understand it better. The assumption behind some discussion of performance, for example, on delayed transfers of care, is that much variation in performance is unwarranted. But we simply don’t know.

Provide consistent levels of funding. To fund services, local authorities are increasingly reliant on funds they raise themselves, for example, through the social care precept (an addition to Council Tax). But the authorities that can raise the least through Council Tax tend to be the most deprived areas which, on average, have most need to spend on social care. Returning to a model of funding that more closely links the need to spend with the amount received is important.

Spread best practice and support poorer performers. The social care sector has never benefited from a fully developed programme to identify and share best practice, such as the NHS vanguard programme. This offered support far beyond that which national social care bodies or local government’s peer review process could provide. There is also little intensive support available to providers who are struggling.

Tighten national oversight. Previously there was independent, national oversight of how well local authorities carried out their duties, but The Care Act in 2014 finally took away the power of the Care Quality Commission to oversee social care commissioning. Some or all of this scrutiny could be reintroduced.

National assessment. An even more radical approach would be to introduce national assessment of eligibility for adult social care (in the same way that eligibility for benefits such as Attendance Allowance and Personal Independent Payment is undertaken by the Department for Work and Pensions). While this would create an opportunity to more effectively join up benefits and social care, it would involve a major shift away from the principle of a social care service that is run by local authorities.

Paying for it: where should the money come from?

Solutions to problems such as poor-quality public services, a workforce crisis and demographic change are normally funded by HM Treasury through Budgets and Spending Reviews. Uniquely, though, social care is often asked to identify the sources of the money it needs for its reform. This is not entirely unreasonable since social care funding is generally recognised to require a partnership between the state and the individual.

If we accept that the question of where the money should come from needs to be answered, there are no shortage of possible solutions. The Nuffield Trust has this guide to the various options and their pros and cons.

Whatever the source, significant investment in social care is essential to improve access and outcomes for users and should be a priority for the government.

Underlying tensions and choices

Behind these fundamental problems in social care are a number of cross-cutting themes. Solutions sometimes involve delicate trade-offs between one aspect of them and another. When considering reform options, it’s important to look at how these issues will be balanced. No reform will be perfect, whatever ‘perfect’ might mean to different people, so it’s important to understand the trade-offs being made.

Pooling risk versus individual responsibility

Different people have different needs for social care over their lifetime and it is not possible to predict who will have greatest need or when. ‘Pooling the risk’ would mean that everyone contributes – for example, by paying into a compulsory insurance scheme or, more simply, by paying tax to government. However, some solutions place greater emphasis on individual’s taking responsibility for their own care in later life, for example, by saving. Others rely on people to risk-insure themselves and if most people did this it would also pool risk but in practice few people take out private insurance. Public attitude suggests acceptance of some individual responsibility but a belief that most risks should be pooled.

Figure 1 Views on the balance of responsibility for social care

Source: Ipsos MORI

Means versus needs

Publicly funded social care is restricted at the moment to people who have the lowest means – savings and other assets – and the highest needs. Eligibility can be extended in either direction. Raising the financial thresholds for care – the amount of savings and assets people can have but still qualify – brings more people with moderate assets into care. Lowering the level of needs they can have in order to qualify brings more people with moderate needs into care. Both have advantages.

Short term versus long term

Concerns about funding in social care are really two issues that often get confused: lack of money to properly fund the current system and the need for even more money to pay for a better one. Sometimes these have competed, as in 2015 when money earmarked for implementation of the long-term Dilnot reform was instead used to plug holes in the existing system. Overall, governments have focused on short-term fixes.

Quality versus quantity

Though ‘better’ does not necessarily always require more money, often it does. Options for improving the reach of social care – providing more support to more people – are therefore likely to be competing for funds with options that improve quality, either directly by paying more for better care or indirectly through, for example, increasing care worker pay. In a world with unlimited resources to put into social care, this would not matter. In a real world of spending reviews, it does.

Simplicity versus equity

Our current, complex system has the advantage of targeting resources most effectively on those with the greatest needs and lowest assets. Universal access to free services, on the other hand, is a simple concept to grasp but doesn’t discriminate between those who might be able to contribute to costs and those who cannot. A national cap or contribution to personal care is simple to understand but doesn’t lead to equal spending power in all parts of the country.

Formal versus informal care

Though most discussion about reform focuses on formal care, the estimated 8.8 million family carers ensure that our social care system works, providing as much care as an extra 4 million paid care workers. The optimum balance between formal and informal care is rarely discussed. Some people worry about a ‘substitution effect’ if more formal care is paid for publicly but simply replaces informal, free care provided by families. Some in fact believe that families ‘should do more’ and even point to an assumed greater role of families in other countries, yet others point to difficulties faced by families who may not live close to each other and to the potential economic inefficiency of people having to give up work to care for relatives.

Conclusion