- Adult social care in England needs fixing – and has done for decades. Increasing numbers of people are unable to access social care and care providers are at risk of collapse. Yet successive governments continue to duck reform, and people and their families continue to suffer unnecessarily.
- Based on our assessment of the evidence and analysis of the costs of reform, five priorities for government are:
- stabilising and sustaining the current system
- improving access to care
- providing social protection against care costs
- seeing the capped cost model as a flexible approach to reform
- exploring a range of options for raising revenue.
- The immediate priority for government should be to stabilise and improve the current system, including by boosting staff pay and improving access to publicly funded care. Stabilising the current system by addressing demand pressures and increasing staff pay in line with the NHS would cost £1.0bn in 2020/21, £2.1bn in 2021/22 rising to £4.4bn in 2023/24, compared to the current baseline budget. Restoring access to 2010/11 levels of service would require around £8.1bn extra investment by 2023/24 on top of this (£12.5bn in total).
- But more fundamental reform is needed to make the funding system fairer and provide government protection against social care costs. Policymakers have choices on how to do this, based on their values, priorities, and public spending plans. A Dilnot-style capped cost model – which focuses extra state funding on those with the greatest lifetime care needs and protects them from bearing costs above a certain limit – could be used flexibly by any government, and already lies on the statute book.
- Any credible reform option requires government investment. The cost of implementing a Scottish-style model, for example, could add around £4.4bn to spending in 2019/20, rising to £5bn by 2023/24. The cost of a Dilnot-style model depends on where you set the cap to protect people against steep costs of care – ranging from around £1.7bn in 2019/20 rising to £2.1bn by 2023/24 under the least generous scenario (a £78,000 cap), to £6.8bn in 2019/20 rising to £7.8bn in 2023/24 under the most generous (a £0 cap – where the state covers all costs of a person's eligible needs).
- Public spending on services in England was £525bn in 2017/18 (in today's prices). Of that, we spent around £18bn on adult social care. Across the whole UK, we spent £22.7bn on social care – 1.1% of GDP. This compared to wider health spending in 2017/18 of £153bn, equivalent to 7.1% of GDP – and projected to grow to 7.9% in 2023/24.
- A range of options can be explored to raise revenue to fund social care reform. Increases in taxation would be an obvious route to paying for a more generous and fairer system.
- Reform is often thought to be unaffordable. But if it chooses, the government can afford to provide more generous care, support and security for vulnerable people in society. If it doesn't, it will be choosing to prolong one of the biggest public policy and political failures of our generation.
In his first speech as prime minister, Boris Johnson promised to 'fix the crisis in social care once and for all', giving 'every older person the dignity and security they deserve'. This promise is welcome: the social care system in England is inadequate, unfair, and unsustainable.
Publicly funded social care – help, care and support that adults of all ages may need as a result of disability, illness, or other life circumstances – is only available to those with the highest needs and lowest means. And cuts in funding mean the number of older people receiving publicly funded care fell by 400,000 between 2009/10 and 2015/16. Many more go without the care they need. Around one in 10 people aged 65 face future lifetime care costs of over £100,000.
But the promise to fix social care isn't new. As prime minister back in 1997, Tony Blair told us that he didn't want our children to grow up 'in a country where the only way pensioners can get long-term care is by selling their home'. Since then, there have been a series of government reports on social care reform – two green papers, four white papers, and various consultations – as well as five independent commissions. Yet there has been no solution to the growing crisis.
Fixing social care isn't simple. Most people are not aware of what social care is, let alone how it works (many think it's 'free' like the NHS) making it hard to sell reform as better than what we've already got. Policy ideas are quickly politicised – labelled a 'death tax' or 'dementia tax'. And the right 'fix' depends on your interpretation of the system's problems. Are you worried about quality of services in the existing care system? The lack of fairness in who gets what? The absence of social protection against catastrophic care costs? The wellbeing of millions of unpaid carers – usually women? All the above? More?
Ultimately, social care reform is political: decisions will be driven by government priorities and values – for example, about the balance of responsibility between individuals and the state. But they should also be underpinned by evidence and analysis.
In this article, we outline five messages for government about priorities and options for social care reform in England, based on our assessment of the evidence and analysis of the costs of reform. In considering these options, we focus primarily on changes to the funding system. Other policy questions, such as the relationship between the NHS and social care, are not covered.
So: if the government wants to fix social care, what should it do?
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