What has gone wrong with social care in England?

Boris Johnson is not the first to try to fix the problems that have made care costs unaffordable for many

How has social care been funded?

Whether it is help with washing and dressing at home or long-term nursing support, most social care in England has never been automatically free at the point of use like the NHS.

Since the 1948 welfare state overhaul, councils have been tasked with helping the most needy, but social care has always been means-tested with delivery left to town halls, charities and private companies.

And in the last decade the means test has become meaner even as demand for help has risen.

Today if you have assets of less than £14,250 you pay nothing and councils cover costs. But if you have more than £23,250 you pay for everything. More than half of residents in elderly care homes pay all or some of their fees and 82% of places are provided by for-profit operators, according to LaingBuisson, a research company. Councils that do pay are essentially responsible for ensuring care is delivered but not how it is delivered, leaving the providers to tackle that question albeit under regulation.

Even in the 1980s there was an acknowledgment that funding was inadequate, but changes centred on the organisation of the care. A 1986 report commissioned by Margaret Thatcher’s government concluded “community care is a poor relation; everybody’s distant relative but nobody’s baby”.

What attempts have been made to fix it?

In the early 1990s there was a policy of targeting limited resources at people’s greatest needs, which resulted in the withdrawal of support for lesser needs and a raising of the threshold for help.

In 1998, New Labour tried to shift the focus to lesser-level needs to prevent people’s problems escalating but again the question of a major funding overhaul was not addressed.

In 2010 the Dilnot commission turned its focus to the impact on family finances, estimating that while half of people aged 65 and over will spend up to £20,000 on care costs, one in 10 would face a bill of more than £100,000. Andrew Dilnot said the government should cap an individual’s contributions to their care (but not board and lodging) at £35,000 and quadruple to £100,000 the assets a person can hold before having to pay. This is the policy now under discussion (albeit with a higher cap), but again it does not mean greater resources for social care which many argue are needed to increase skills, pay, integration with the NHS and use of technology. Rather it is a shift in who pays.

What is the impact on families of the current system?

For the hundreds of thousands of families paying 100% of care costs, bills stack up very fast, especially when loved ones have long term-conditions. Katie Meacock, part of the Rights for Residents campaign group, is selling her mother’s flat to pay for her care fees. Caroline Hockter-Duncan, 75, has advanced dementia and moved into a £4,800 a month care home six years ago, and after the fees rose to £7,000 her savings ran out. She has already spent more than £400,000.

Meacock described the financial uncertainty as “incredibly stressful” and said it had compounded an already difficult decision to send a loved one into care.

Others who run out of money have to move often highly vulnerable loved ones out of privately funded care homes into council-funded care, which is considerably less well resourced. Such moves can be highly distressing and even dangerous for health.

While raising taxes to pay for a Dilnot-style cap would help people like Meacock, there is no sign yet of more money to meet rising demand.

What it would cost

Why is demand rising?

Between 2016 and 2020, the number of people requesting social care support increased by 120,000 but about 14,000 fewer people received it, according to the King’s Fund thinktank. There are now more older people, partly as a result of the postwar baby boom and partly because older people are living longer. There are also more working-age adults with disabilities: 19% in 2019-20 compared with 15% in 2010-11.

What is the cash shortfall?

Somewhere between £6bn and £14bn a year, estimates the Health Foundation charity. This depends on whether ministers want to meet the rising need while maintaining standards or improving them. It is as yet unclear whether any of the £10bn that may be raised if national insurance is increased will go to this or simply to covering costs currently met by families.

By a large margin, public opinion is that we do not spend enough on social care. Yet spending per person is below a decade ago. In its last annual report, the Care Quality Commission described the sector as “very fragile” and the Association of Directors of Adult Social Services said this summer close to 75,000 disabled and older people and carers were waiting for help in England. While the Covid pandemic has increased the focus on elderly care, council bosses are most worried about providing for people of working age with disabilities.


Robert Booth Social affairs correspondent

The GuardianTramp

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