Despite widespread agreement that the provision of social care in Britain should be improved – and endless reports and debates – little has changed for over a decade…
The coronavirus pandemic and its impact on care homes should provide a stimulus to resolve the long-recognised problems with social care. But there is still little sign it will – despite an excellent, affordable set of remedies set out by the Dilnot Commission nine years ago.
Adult social care – looking after non-medical needs – costs over £50 billion each year. That does not take account of people whose families look after them or who have enough money to pay for care directly. These costs will rise as the number of older people increases significantly, and the care needs of working age people are expected to grow too.
Boris Johnson said when he became prime minster in July 2019 that his government would “…fix the crisis in social care once and for all with a clear plan we have prepared, to give every older person the dignity and security they deserve”. In October 2020 he told the Conservative Party conference, “We will fix the injustice of care home funding. We will care for the carers as they care for us.”
Reality
The reality is quite different; not much has changed with this government from the last. The then Chancellor Phillip Hammond announced in March 2017 that there would be a Green Paper (consultation) about social care and how it was funded. Nothing has really happened since then despite two general elections, a change of government and different ministers responsible. But they did find the time to reorganise and create a new Department of Health and Social Care.
Johnson promised that rather than an open-ended consultation, his government would set out definite proposals in a White Paper, but that has not appeared. Coronavirus is just one more reason nothing has been done.
‘Not much has changed with this government from the last…’
Delayed release from hospital is often seen as the main impact of inadequate social care provision. Delayed release is certainly a big problem, costing the NHS in England over £450 million each year according to the National Audit Office, although not all of that is due to social care shortcomings.
The impacts of poor social care are more widespread. Firstly, the impact on those needing care themselves: their dignity and life are diminished. Without adequate care their health is affected, resulting in increased medical needs of many kinds. Family members often have to stop work or reduce hours. And for many there’s the fear of the high costs of care.
The number of people needing social care is hard to estimate, as official figures are fragmented by devolution to Wales and Scotland and cover only those receiving support. But there were over a million people needing it in England alone in 2018/19, according to the Kings Fund. About 840,000 received long-term publicly funded care and a further 220,000 needed short-term care.
Those figures are expected to grow, primarily due to an ageing population. But there are other factors too – such as the rise in obesity and poor housing, both of which can drive the need for care support.
Again it’s hard to estimate the number of paid carers due to the fragmented and largely private provision. But it’s comparable to the NHS. The King’s Fund estimates that there are 1.6 million – including care workers and registered nurses. Most are employed by small and medium-sized private homes. And there are around 140,000 employed directly by care users.
Pay
Employment in the care sector is notoriously low paid and poorly organised. In addition many care homes are not financially sound. Those relying on local authority placements find that what they receive does not meet costs. It was no surprise to anyone that the demands of responding to coronavirus found many wanting. But it’s important to note that 67 per cent of all care homes in Britain reported no cases of Covid-19 infections amongst their patients by July 2020.
Care is funded through local authorities, paid for by central government funding and council tax. That’s true for Wales and Scotland too, but those administrations with devolved powers make separate funding decisions. Just under half of the spending is on adults of working age.
Local authorities suffered cuts in social care funding between 2010/11 and 2014/15. Spending has risen since, including tranches of emergency funding, even before 2020. And despite protecting social care budgets at the expense of other responsibilities, local authorities argue, quite reasonably, that there’s still a significant shortfall. That’s due to both rising numbers and the rising cost of care.
And yet the situation is worse than that. Most of those who apply for care do not get support, frequently because of the financial means test operated in England and Wales. The funding of long-term care has been the sticking point which has delayed reform.
The idea of a service free at the point of care is obviously attractive. How might that be funded and organised? To add social care to NHS responsibilities isn’t the answer. It would distract from what the NHS has to do and would not resolve either funding or organisational issues in care provision.
Alternatives
So what’s the alternative? Returning social care to be a local authority function once again is not necessarily an answer. Social care has changed. Local authorities now rely on multiple fragmented private businesses or on people directly employing carers. That’s neither efficient nor a sustainable basis for long term reform. So if there is not enough money for the current arrangements, how can we achieve free care at the point of delivery?
The TUC and Unison rightly point to the cuts in social care funding, the high number of vacancies in the sector and the prevailing low wages. But the problem goes much deeper.
The Dilnot Commission was set up in 2010 to address issues associated with care of the elderly. Its recommendations have not been implemented, but they are just as relevant today. It aimed to eliminate the catastrophic care costs some people faced by capping the amount individuals contribute over their lifetime. Beyond that the state would meet all future funding.
The idea was that limiting people’s liability in this way would help to develop a market for financial products so that people can insure themselves against the cost that they were likely to incur. The Commission also recommended that those in need of residential care should make a standard contribution towards living costs.
Assets
More importantly it said that the asset threshold above which people in care are liable for its full cost should be raised from the current level of £23,250 up to £100,000. The asset threshold has not risen much since then while local authorities have struggled to balance their budgets. It also means even more people will face catastrophic funding costs or – more likely – just not get the care they need.
Dilnot said that criteria for services should be set nationally and needs assessments should be portable between local authorities to prevent a potential post-code lottery. Devolution to Wales and Scotland, and local authority regionalisation in England, have made uneven support worse. Any solution to the funding and organisation of care ought to return to national standards, even if delivered locally.
The Dilnot Commission’s recommendations if implemented in full would have cost £1.7 billion for 2010/11 rising to £3.6 billion by 2025/26 (at 2010 costs), including forecast demographic changes. That’s less than 1 per cent of GDP, and much less than the bank bailout after the 2007-2008 financial crisis.
There was no conceivable financial reason to stop these proposals being implemented. It was a political decision to marginalise the elderly and their families at a time in their lives of greatest need. The apparent government indecision since 2017 begins to look more like deliberate delay.