Why does adult social care matter?
Responses to the consultation demonstrate an unequivocal view of the importance of adult social care and support. That importance is defined in different ways. Some frame social care as a moral responsibility, a hallmark of a civilised society and as an issue of human rights. Others note the role it plays in enabling people to maintain or regain their independence, with a clear linked emphasis on the ability of social care to help prevent, reduce or delay the onset of needs. A clear proportion of respondents define the importance of social care in terms of helping people enjoy the best possible quality of life, including their participation in, and contribution to, society. Some respondents noted that social care acts as a ‘universal safety net’ and others acknowledged its importance in supporting unpaid family carers. Finally, a significant number of respondents spoke of social care’s wider contribution to society, such as in economic terms and in linking to other public, private and voluntary services.
The majority of respondents also believe it is important that decisions about social care are made at the local level, recognising that a ‘one size fits all’ approach cannot work given the differences between local areas. Furthermore, respondents acknowledged the importance of democratic accountability and locally held knowledge. However, the consultation also revealed a degree of concern about a ‘postcode lottery’ of social care, with some respondents believing a local approach to social care within a framework set nationally is best.
There are as many answers to this question as there are people involved in any aspect of the social care and support and wellbeing sphere. But they all point in the same direction: adult social care and support matters because people’s lives matter.
The problem, not discovered by our consultation but certainly reinforced by it, is that the value of social care is not recognised beyond that sphere. It is not part of the national psyche in the same way that the NHS is, or other fundamental institutions in our society that we instinctively appreciate despite any shortcomings, such as schools and education.
The first step to bringing about any change is building an awareness of what it is that needs changing and why. That helps raise appreciation, and in turn, builds momentum for a commitment to change.
Our consultation also underlines a well-known tension within the care and support system: recognition, and support for, the local dimension of social care on the one hand, but concern about variability on the other. One is not more important than the other, but the presentation of the issue sometimes implies that is the case. This must change.
The funding challenge and its consequences
Individuals and organisations with a commitment to social care and support have, for some time, outlined the pressures facing the system and their implications. In one sense, our consultation therefore reveals nothing inherently ‘new’. However, the findings from our consultation underline this fundamental truth and bring it into the sharpest possible focus across several hundred responses that powerfully capture the human cost of our struggling care and support system.
All respondents – individuals, councils, providers, workforce and voluntary sector organisations – have described a system that is now failing across the board as a clear consequence of underfunding: the situation is “disastrous” and “catastrophic”. People’s needs are not being met, services are being withdrawn, quality is deteriorating, improvement is stalling and in some cases is in reverse, the ability to prevent the need for social care in the first place is rapidly being lost, providers are unable to stay afloat and unpaid carers and the care workforce are being put under impossible and unbearable pressure.
At the most important level, the implications are being felt most acutely by people. People who are “sad”, “lonely” and living “undignified” lives. People whose lives have now, in the view of one respondent to our consultation, “been put at risk”.
The breadth and depth of the historic and current funding challenge, and its consequences, is enormous. Short-term pressures must be addressed properly to stabilise social care and support now and as a down payment on longer-term reforms. A failure to act properly now will exacerbate the consequences of under-funding we have seen to date. Lives will not be lived to the full, quality and improvement will stall or reverse, unmet and under met need will rise, businesses will be at risk, demand on the NHS will increase, pressure on the workforce and unpaid carers will rise, investment in prevention will decrease, and local communities will be fundamentally weakened. Not acting now will only increase costs over the longer-term, whether that be for councils or other parts of the public sector.
The options for change: changing the system for the better
There is a clear message from across respondents that more funding is needed, both for the immediate-term and beyond. Where respondents selected specific issues to address as immediate priorities, the most common selections were paying providers a fair price for care and covering the cost of inflation and the additional people needing care and support. There were linked issues around quality and the care workforce. Implementing a ‘cap and floor’ and free personal care for all were only selected by a small proportion of respondents as being most urgent to address now.
Looking to the medium-term and 2024/25, the most commonly chosen priorities were free personal care and providing care for those who need it, although these were only selected by one in 10 of respondents. For the future (ie beyond 2024/25), free personal care and a ‘cap and floor’ were the most commonly selected priorities, but again chosen by just over one in 10 respondents and just under one in 10 respondents respectively. Within the public polling, ‘making sure everyone who needs care is able to access it’ was the clear priority for the future.
The findings for this section of our consultation are largely reflected in the commentary above on the funding challenge and its consequences. This is particularly true in terms of immediate priorities, which were identified as stabilising the provider market and covering the cost of inflation and demography. What this section does reveal however, and looking to the medium and long-term, is that there is no clear and widespread support for implementing a cap on care costs and a floor for asset protection.
Free personal care had slightly greater support for the medium and long-term, but it was still not selected by a large proportion of respondents (just over one in 10 of those who answered). This is not to say that these ideas are not without merit and, indeed, people’s understanding of that merit would likely be increased if there was a more general and better understanding of social care and its value, as identified above.
When considering exactly how to raise awareness, it will be important to consider the finding from our focus groups and public polling that, whilst people think it is right to contribute to one’s care costs, only 22 per cent believe that the £23,250 threshold (above which people are expected to contribute the full cost of their care) is set at the right level. Fifty-eight per cent believe only those with assets and income over £100,000 should contribute to social care costs.
Similarly, in explaining options to the wider public, it will be important to be clear that while a cap on care costs would help to pool risk, it would still cost a significant amount of money. Equally, free personal care could be seen as a zero cap on care costs so, in this sense, they could be presented as a spectrum of options.
The options for change: how to pay for these changes
In many ways, this is the most important part of our consultation as the answer to how we pay for social care for the long-term is what has eluded many previous attempts to reform social care funding.
The consultation revealed that the most popular potential solution is increases to National Insurance (NI). Respondents favoured this for a number of reasons including the progressive nature of NI, the fact it would provide a national solution to a national problem, the relative ease with which the solution could be administered and the fact that it would raise a significant amount of money.
Increases to Income Tax was the next most popular option for broadly similar reasons to the appeal of NI.
Means testing benefits was the third most popular option but there were more concerns attached to this solution, such as the likely high costs of implementation and administration and the fact it would not raise sufficient funding for the size of the problem.
The consultation revealed no clear consensus on bringing wider welfare benefits together with other funding to meet lower level needs.
The additional material was similarly illuminating. The findings from the focus groups point to a wider set of issues which, in many ways, contextualise the discussion about how to change the system for the better and then pay for those changes. These also relate to people’s understanding of social care; what it is and how it is funded, for instance.
The focus groups showed that learning more about how the system works provokes a very emotional response – in particular a considerable resistance to means testing and the perceived unfairness that people who have ‘done the right thing’ might have to sell their homes to pay for care.
This links to a tension that was also brought out in the focus groups: recognition that the system needs more money on the one hand, but a reluctance to contribute on the other based on a number of concerns including notions of ‘fairness’, the squeeze on households budgets and consequent feeling that people would not be able to pay an additional cost, and a lack of trust in government and subsequent concern that funding would not get through to social care.
Our public polling reinforces others’ surveys in respect of people’s lack of planning for future care costs. However, a clear majority (67 per cent) recognised it is fair for people to pay for some of their care costs if they can afford to do so, and a significant proportion (45 per cent) went further, agreeing that it is fair for people to pay for all of their care costs, if they are able to.
In terms of solutions for the long-term, the public polling mirrors our consultation in that the most favoured option is increases to NI (56 per cent of respondents). Increases to Income Tax were favoured by just under half of those polled (49 per cent).
On the idea of social insurance, our public polling showed that 56 per cent of people would support paying extra for social insurance. Compulsory payments were the preferred way for payments to be made, with 65 per cent believing such payments should apply to everyone of working age, compared with 21 per cent believing payments should only be made by those over the age of 40. Fifty-five per cent believe payments should be taken straight from one’s salary, 8 per cent believe there should be a one-off payment upon retirement and 17 per cent believe a one-off payment should be made from an individual’s estate upon death.
Our polling of council leaders and cabinet members for social care shows that an overwhelming majority (82 per cent) believe that the risk, and therefore cost, of social care should be pooled. Of the options provided in terms of solutions, councillors clearly favoured increases to Income Tax. Increases to NI was the lowest of the five most popular options, but it still had the support of 63 per cent of councillors.
If one of the most significant findings of our consultation is that people are prepared (either instinctively or after learning more about how the system operates) to support national tax rises, then one of the most significant implications is that, at the very least, this option must not be ruled out in the Government’s green paper.
This is not to say that this would represent an ‘easy’ funding solution (or solutions). Any government would face similar difficulties in explaining how the system works now, building a case for the public to pay more, and then implementing tax (or other) changes to raise that funding. This may partly explain why previous attempts at reform have ultimately failed.
What is potentially different now – as is evident from our consultation and others’ work – is that the difficulty could be at least partially offset by the public’s willingness to proceed with the bolder option of tax rises.
Of course, the other implication from this part of our consultation is that building such willingness amongst more members of the public will require a careful and concerted campaign to explain the issues and the need for, and merits in, more radical solutions. Key to this will be exploring people’s strong feeling that one’s home should be able to be passed down to one’s children. In this sense, national tax rises may be considered the best of different, potentially unpalatable, options.
Adult social care and wider wellbeing
Responses paint a clear picture of the significant inter-relationships between a range of services that all have a role to play in promoting health and wellbeing. An equally clear picture is painted of the pressures facing these services.
Public health was recognised as having an important role to play in improving health and wellbeing, both in terms of its broad preventative function but also the evidence base it provides and which helps with service planning and commissioning.
A broad range of examples were given that illustrate the important interaction between services and sectors that are at the heart of building health and wellbeing. Social projects (such as those promoting physical health, education and employment), environmental projects (recognising the role of housing, transport, parks and green spaces), resilience projects (such as advocacy, navigating and signposting services) and behavioural projects (tackling, for instance, smoking, obesity and substance misuse) highlight the complex inter-play of services that strengthen community wellbeing and independence.
Respondents clearly believe that these wider wellbeing services are under pressure, with the majority of comments indicating that local areas are seeing a significant reduction in these services overall. Of particular note, several respondents spoke of the reduction in funding available for voluntary and community sector projects (at a time when that sector is also facing increasing demand).
There is clear recognition of the role and value of public health, housing and other local services in contributing to people’s health and wellbeing. It is also clear that there is an important interplay between these services and the outcomes they achieve. Effective and integrated transport systems help people remain independent, allowing them to access services such as libraries, that help tackle loneliness, parks, which can improve physical wellbeing, and advice, advocacy and sign-posting services, that may assist with housing or employment issues.
But it is also clear that cuts to such services have been part of the approach to protecting adult social care budgets. This is counter-productive. It reduces councils’ ability to positively influence the wider determinants of health, which can then limit people’s potential and their own contribution to building resilient communities.
Adult social care and the NHS
Respondents clearly felt it was important, very important, or extremely important that decisions made by the local NHS are understood by local people and that decision-makers are answerable to local people. Linked points were made about the need for greater transparency in local NHS decision-making and the importance of involving local people in the decision-making process.
Slightly more than half of the respondents who commented on the role of health and wellbeing boards (HWBs) said the structures should be strengthened.
Of the suggestions given in the green paper for strengthening health and wellbeing boards, the two most popular options were requiring sustainability and transformation partnerships (STPs) to engage with HWBs in developing STP plans, and giving HWBs statutory duties and powers to lead the integration agenda locally.
On the use of the new funding for the NHS, and amongst those who responded to the question in relation to the suggested uses set out in the green paper, the most popular suggestion was to invest in prevention, primary care and community health services, with multi-agency teams working closely alongside the voluntary sector to put in place early help and support.
There is a strong and consistent message that the NHS needs to be more open and accountable to local communities, by directly involving local people in meaningful discussions about local health services and also through existing local democratic structures. In particular, health and wellbeing boards – the only statutory body where political, clinical and community leadership comes together to agree shared priorities for improving health and wellbeing – are identified as the best forum for ensuring that health services are accountable to local people.
Many respondents want stronger powers for HWBs, especially in leading local integration of health, wellbeing and care services and in ensuring that sustainability and transformation partnerships and integrated care systems build on, rather than cut across or side-line, existing plans for joining health and care services.
Regarding additional funding for the NHS, there is a preference for investment in prevention at primary and community level in order to enable people to stay healthy and independent.