Following the government’s announced social care reforms in September 2021, JPIT’s Paul Morrison provides a guide to some of the issues involved.
What is social care?
Social care covers a wide umbrella of services to people of working age as well as the elderly. It varies from light touch support to help people stay active and engaged in their communities, to regular personal care visits to help with washing or dressing all the way through to long term nursing home care. For some, the care is simply essential for life, and for many more social care offers the opportunity to maintain a dignified and connected life.
Good social care can transform lives, but bad or absent social care can ever so quietly close people off and strip them of their dignity. Both good and bad care often go unnoticed by all but very close friends and family.
Who gets social care?
Adult social care is used by adults of any age whose needs [1] are assessed to be significant enough to warrant support. The service is particularly needed by people of pension age who account for two-thirds of the 800,000 individuals receiving long term care, and just under over half of all social care spending. This does however mean that support for working age people with disabilities or impairments forms a sizable and often overlooked component of social care.
Why does social care need reform?
The case for change falls into three broad areas of concern [2]:
1. There are not enough social care services available to meet the need: Local authorities in England receive around 2 million new requests for help each year, and for a variety of reasons reject around 42% of them. The number of requests is steadily rising, levels of reported disability are rising, but the numbers receiving long term care are steadily falling. Other surveys indicate that 1.5 million over 65s who need and are entitled to care do not receive it. Increasingly stretched local authorities have had to spread their resources more thinly.
You only need to talk to families who have dealt with the care system to know that the effect of this is to make it much harder to ensure loved ones are cared for with dignity. The system can appear to be a confusing, guilt inducing maze. Unfortunately to ensure good care families are often required to have sufficient money to top-up the basic care packages on offer, and/or the ability to put their case to the local authority persistently and well.
2. Care staff have persistently been undervalued: There are around 1.5 million people working in the care sector. In Scandinavia, care work is viewed as a profession with progression, training programmes, and wages at around three quarters that of a nurse’s. In the UK care work is viewed as a low paid, low skill occupation with a limited career pathway. By 2019 average pay had slipped back relative to other low paid jobs, and for example is now below that of retail assistants.
The job can be difficult and demanding and given the low pay and status we cannot be surprised that each year almost 1 in 3 carers leave the profession (for home care workers it is nearer 1 in 2), and that recruitment is a persistent problem.
Even if not financially rewarding, care-giving can be a hugely rewarding job. However, when surveyed, three quarters of domiciliary carers said that cost pressures meant they did not have time to provide dignified care.
3. For some people care is very expensive, even to the point of needing to sell their home to pay for it: Unlike the NHS, social care is not free when you need it. Essentially if you have assets of over £23,250 then you must foot the full cost of care, and may need to pay a proportion of costs if you have assets below this threshold. The ‘housing disregard’ means that if you need to continue living in your own home, the value of your property is not counted in your assets, but if you move into residential care it does then count.
Fees for care can quickly become substantial, and the government estimates that 1 in 10 adults will face costs of over £100,000.
What reforms are being proposed?
The Command Paper contains 3 sections. The first about the NHS, the second about social care and the last about a 1.5% rise in employers and employee’s National Insurance contributions. This tax increase is branded “the Health and Social Care Levy” and will raise an additional £11 billion [3] to be divided between the NHS and the social care sector.
Changes to means tests: There is a fairly detailed answer to the issue of families needing to pay high fees for care. It sets a cap where once a person has paid £86,000 they will not be asked to pay any more for their care.
The means test is also restructured, so that if you have assets of less than £20,000, no care fees are payable; between £20,000 and £100,000 a contribution of disposable income and up to £20,000 per year may be charged; and over £100,000 the person must pay full costs.
The annual cost of this will be around £1.6 billion, but this is not additional money to the sector to improve services – local authorities will lose some fees from people with assets, but they are replaced by money from National Insurance contributions.
Few specific commitments to social care: Ironically for an announcement billed as ‘fixing social care’, beyond the funding reforms, there are very few commitments to change or even provide additional funding to social care. The paper says encouraging if familiar things about the system and promises that a White Paper will be forthcoming. However the only additional money it specifically offers the sector is £160 million per year to provide a helpline and other support for care staff.
Costs in context: The care system costs £23 billion a year, and the Health Foundation estimates that by 2023 an additional £1.9 billion is needed to simply keep pace with current demand. £160 million will not go far – nor does the paper suggest it will. It is currently unclear how much of that £11 billion will go to the NHS and how much to social care.
[1] The criteria of sufficient need is defined in the Care Act 2014, and set at what I found to be a surprisingly high level.
[2] Experts will rightly accuse me of oversimplifying the issues. If you are interested in more detail go to the excellent and readable Kings Fund Social Care 360 website https://www.kingsfund.org.uk/publications/social-care-360
[3] after taking into account increased benefit payments and costs to public sector employers
