An assessment of the government’s social care policies over the past 10 years indicates a mixture of real progress and continuing problems.
How many people need social care?
Demographic and social change will continue to place social care services in England under growing pressure in the years ahead.
By 2026 the number of people over 85 will have doubled – and the number of those over 100 will have quadrupled (Office of National Statistics, 2007); the number of adults with profound and multiple learning disabilities will also have increased by 37 per cent (Emerson and Hatton 2008).
Evidence suggests that although people are living longer, they are not necessarily more healthy. People are spending a longer time living with conditions that seriously reduce their quality of life, such as arthritis, the effects of a stroke, or dementia. Current trends in obesity and other lifestyle-related diseases will also increase the need for care.
Currently, there are around four people under 65 for every one person aged over 65; by 2029, there are expected to be three people under 65 for every person over 65 (ONS 2007).
What has the government done?
The government has produced some wide-ranging and comprehensive strategies, often as part of wider cross-government initiatives – for example, for carers, those with dementia or learning disabilities. Earlier policy initiatives such as the national service framework for older people were well received, but their impact on people's experience and outcomes is unclear.
In 2008 a major programme, Putting People First, was introduced to transform adult social care, with personalisation as its cornerstone. Specific initiatives on extra care housing, prevention and the use of technology have sought to promote new service models. Care and support will increasingly be arranged through personal budgets.
This focus on social care policy has generally been well received by the social care sector and wider stakeholders; some, such as personalisation, enjoy cross-party support. However, it is too soon to assess the impact of many of these policies.
How much has been spent?
Between 1997 and 2008 public spending on adult social care has risen by 53 per cent, an average increase of 4.3 per cent per year, although the rate of increase slowed towards the end of this period. The overall increase is similar to that for many other public services over the same period, but much less than the increase for the NHS. Both the Labour and Conservative parties have committed to ringfencing most of the NHS budget, but no political party has made that commitment to social care spending.
Source: NHS Information Centre, figures exclude the Supporting People programme
However, the increases in funding have not kept pace with rising pressures on services, fuelled by an ageing population and more people with disabilities. Although some of the strain has been absorbed by increases in council tax (now accounting for 39 per cent of public spending on social care), councils have rationed care by raising the threshold of who can qualify for help. By 2009, nearly three-quarters of councils were helping only those with substantial or critical needs (CQC 2010). Growing numbers of people make their own private arrangements, rely excessively on informal carers, or simply go without help. One estimate suggests that at least 300,000 people have substantial unmet needs, but this information is not collected systematically (HoC Health Select Committee, Social Care, Third Report of Session 2009-10).
How good is the care?
The 1998 White Paper, Modernising Social Services, introduced national minimum standards, national performance assessment of local councils and independent inspection of care services. New bodies such as the Social Care Institute for Excellence and the General Social Care Council were established to promote quality and drive up standards.
Measured against national standards set by the regulator, 95 per cent of councils were rated as 'good' or 'excellent' for the care they secured for local people, and no council was assessed as poor. The quality of care has also improved year on year, with 77 per cent of providers rated as good or excellent in 2009 (Care Quality Commission 2010). But overall improvements in performance can conceal wide variations between providers and councils – the so-called postcode lottery. For example, there is a three-fold difference for older people and a seven-fold difference for adults with learning disabilities in the number of admissions to residential care (Department of Health 2009).
How well integrated are health and social care?
People's needs do not always fall neatly into separate 'health' and 'care' categories; these needs can only be met effectively where the NHS and social care are joined-up around the needs of the individual. One study found that 90 per cent of people receiving social care also received secondary health care over a three-year period (Nuffield Trust cited in CQC 2010).
There is growing evidence that more can be achieved when resources are used jointly across health and social care. Integrated early intervention programmes can generate savings of £1.20-£2.65 for every pound spent (Turning Point 2010). Prevention and early intervention schemes for older people help to reduce emergency hospital admissions and can produce £1.20 savings in emergency bed days for every £1 of additional investment (Personal Social Services Research Unit 2010).
The government aimed to remove the 'Berlin Wall' between health and social care and introduced a number of policy levers to help achieve this: care trusts (in which councils and primary care trusts (PCTs) combine their health and care services into a single body); new legal powers ('flexibilities') to integrate provision, pool budgets and jointly commissioned services; and requirements to produce joint plans, for example, joint strategic needs assessments. In some areas this has worked well – for example, the expansion of council-funded intermediate care to prevent hospital admissions and joint action to reduce delayed transfers of care from hospital – but in other areas progress has been mixed.
Is there hope of reform?
The need for reform was recognised as early as 1998, when the government established a Royal commission on long-term care, although it did not accept its recommendations for free personal care. It was not until 2009 that the government set out options for consultation in the Green Paper Shaping the future of care together. A Bill providing for free personal care at home, which was not recommended in the Green Paper, was introduced later that year. Other proposals were published in a White Paper just weeks before the general election. Funding of social care is likely to be a major issue in the election campaign and for the first time 'care for elderly and disabled people' is mentioned by the public in Ipsos MORI polls on the list of issues that will determine how they vote.
What do the three main parties say about social care?
All three major parties are committed to personalisation, closer working between health and social care and a stronger role for the third sector. All are interested in promoting different models of service delivery based on mutual and social enterprise principles.
Labour's manifesto reiterates the proposals set out in the White Paper Building the National Care Service, namely:
- From 2011, free personal care at home for those with the highest needs.
- From 2014, a cap on the costs of residential care so that everyone's homes and savings are protected from care charges after two years (paid through freezing inheritance tax thresholds, supporting more people who choose to work beyond retirement age, and driving through efficiencies in the NHS and social care system.
- From 2015, a comprehensive service free at the point of use for all adults with an eligible need.
- Establishing a commission to reach consensus on how the service should be financed, making recommendations in time for proposals to be put to the public at a general election.
The Conservatives also pledge to 'reform social care'. Their manifesto commitments include:
- Rejecting a compulsory payment in favour of a voluntary one-off insurance premium costing around £8000; this would protect people's homes from being sold to meet the costs of residential care.
- Supporting older people to live independently at home and have access to the care they need – they aim to design a system in which people can choose to top up their premium to cover the costs of care at home.
- Supporting carers, and those they look after, by providing direct payments to help with care needs and by improving access to respite care.
- Offering people with a chronic illness or long-term condition a single budget that combines health and social care funding, which they can tailor to their own needs.
The Liberal Democrats say they will:
- Integrate health and social care to create a seamless service, ending bureaucratic barriers and saving money to allow people to stay in their homes for longer rather than going into hospital or long-term residential care.
- Immediately establish an independent commission to develop future proposals for long-term care, based on the principles of fairness, affordability and sustainability.
- Use the money identified for Labour's Personal Care At Home legislation to provide guaranteed respite care for the 1 million carers who work the longest hours.
- Ensure councils are more involved in commissioning local health services, working closely with elected Local Health Boards (these would replace PCT boards).
In summary, both Labour and Liberal Democrats propose a commission to identify how social care should be funded in the future. Labour's preference is for some kind of compulsory payment that would enable all services to be offered free at the point of use, whereas the Conservatives would implement voluntary insurance. All parties are committed to the further use of personal budgets and direct payments. The Liberal Democrats and Conservatives make specific pledges to improve support to carers.
The biggest single question for all the parties' proposals is – how will they be funded? Will voluntary insurance, for example, generate sufficient take-up to represent a viable solution to the growing funding pressures of an ageing population and the rising numbers of younger disabled people; and will the commissions proposed by Labour and the Liberal Democrats achieve the consensus about future funding options that has eluded politicians to date?