1. Introduction
Various demographic, social and economic shifts across the developed world have increased concern about the ability of these societies to provide sufficient quality and quantity of care for older and disabled citizens. These shifts include changes in gender roles and norms, a fall in fertility rates and the extension of mortality accompanied by related age-related disability and disease.
As populations age and families have changed, so has the way people care for each other. ‘Care’ traditionally described the activity of women in private households, characterised by the provision of physical and emotional support to children and to older and disabled adults. Since the 1990s, it has emerged as a multidimensional concept: referring not only to this private relationship, but to the organisation of ‘social care’ services delivered by the state, market or through civil society and community organisations designed to help people to live more independently and participate more fully in their communities and society. More recently, it has come to be defined as activity that promotes ‘wellbeing’, for example in the English Care Act 2014.
Although support for adults with needs relating to frailty and disability has long been of concern to UK policymakers, harking back to the Victorian Poor Laws, ‘Adult Social Care’ is a relatively new concept in the field of social policy. Its history is related to the growth of welfare provision for children and community health services. Adult social care only became a truly distinctive area in 2005, when concerns about the quality of children’s services prompted an organisational separation of adult and children’s services within local government.
Public social care services are available to people who are assessed as having an eligible care need, due to disability, age-related frailty or a mental health condition. They encompass a range of types of support, including residential care, care in the home and services to maximise community participation. Unlike NHS services, social care services are means-tested, and people with assets above a certain level are required to pay for some or all of the costs of their care. There is no definitive data on the number of people who pay for their own care, but it is estimated that by 2011, 170,000 people fund their own domicilary care (around 25% of the market) and 170,000 in residential and nursing care (up to 45% of the market) completely self-fund (Baxter, 2016)
Public social care in the UK is a local government domain, and each local authority has somewhat different approaches to assessing need and putting in place support. Most care services are now outsourced to private and not-for-profit providers – with, for example, 95 per cent of residential care provision coming from one of these sources. Local budgets for care services have been hard hit by public service spending cuts in recent years, even despite recent increases. According to the IFS (2018), local government expenditure fell by 10% in real terms between 2009-10 and 2014-15 before recovering by 7% between 14/15 and 17/18.
2. Key concepts shaping social care
There are a number of concepts which have been influential in shaping the scope and intent of social care services in recent years. These include:
3. Current social care policy
Recent social care policy in the UK has focused on sustainable funding of the social care system across the four nations of the UK. Debates over the sustainable funding of a system to support older and disabled adults and their carers are not new, nor unique to the UK. Across the developed world, states are grappling with the implications of various demographic, social and economic shifts including a significant increase in female workforce participation, a fall in fertility rates and the extension of mortality accompanied by related age-related disability and disease. A growing demand for care is one as a result of these shifts, and the fair financing of a system to accommodate this demand has become a central issue for the UK’s governments and governments worldwide. These demands are increasing while funding available to local authorities (with a statutory responsibility for delivering, or purchasing care) has been falling for almost a decade, following the 2008 financial crash and resulting shortfall in government revenue.
The central questions involved in funding reform are:
• What is the right balance between individual and collective contribution?
• What level and quality of service is appropriate?
• What is the right balance between means-tested, universal and contributory benefits?
UK governments of various compositions have launched a number of policy initiatives over the past 20 years that attempt to provide answers to these questions and to find a level of consensus around them. The debates around the funding and related composition of the social care system have inevitably been politically fractious and have prevented significant action by UK governments, while the divergence in funding systems with the devolved administrations has largely come from partial adoption of UK-wide commission and report recommendations.
The Blair-led Labour government established a royal commission in 1997 that published its report ‘With Respect to Old Age’ in 1999. Published in two parts, the report reflects the split among the commissions membership on a way forward. The majority recommendation was for the state to arrange for personal care to be free, while the minority report argued that this recommendation was unaffordable. In Scotland, the devolved Labour/Liberal coalition government implemented the recommendation of free personal care.
The most recent serious attempt to offer a solution to the growing demand for care and the seemingly unfair current settlement came with the publication of ‘Fairer Care Funding’ the report of the Commission on Funding of Care and Support led by Andrew Dilnot (2011). The report argues that care remains the last large uninsurable social risk: private insurers have failed to produce products while enable us to pool this risk through the market. However, the report stopped short of proposing the establishment of a national insurance fund (in line with developments in Germany and Japan), and set out a series of recommendations to introduce a series of reforms to the existing means-tested system. At the bottom end, the report proposed raising the asset threshold from the existing £23,250 to £100,000, expanding the number of people who would receive free care. It also proposed a cap on the amount any individual or family would contribute toward their care: £72,000. The commission hoped that establishing a clear picture of the maximum risk an individual would face, would encourage insurance companies to provide policies that would protect individuals. These recommendations influenced the composition of part 2 of the Care Act 2014; however, the lifetime cap was set at £75,000. The newly elected Conservative government shelved the funding in 2015 until 2020.
Following Theresa May’s election as leader, the Conservatives proposed the publication of a Green Paper putting forward new proposals in the autumn of 2017. During the 2017 general election campaign, the government re-launched proposals even further removed from the commission recommendations: eschewing the lifetime cap and retaining the £100,000 threshold. They also proposed the inclusion of the value of people’s homes when means testing for home care, not only for nursing and for residential care. The reaction to the proposals made a large impact on the Conservative election campaign, with many perceiving the changes to be regressive, or a reduction in service. Political opponents labelled the changes a ‘Dementia Tax’. Theresa May famously declared ‘nothing has changed’ during a press conference to discuss the proposals and announced that yet another set of proposals would be set out in a government Green Paper.
Scotland’s 2002 introduction of free personal care for over 65’s represents the clearest departure among the devolved administrations from the UK government funding approach. It also provides the opportunity for something approximating a ‘natural experiment’: a chance to measure the impact of a particular approach to charging policy, although the feasibility of this has been called into question: parallel policy developments in Scotland and the UK make it difficult to establish causation. However, a number of studies have discussed the impact of policy observing:
• A growth in the number of free home care packages, together with a reduction in overall home care packages
• The impact on Attendance Allowance: Scottish Care home residents who receive free personal care are ineligible for this disability benefit
• The rationing of other forms of care and support by local authorities in order to manage the additional cost of free personal care
• A lack of public understanding about what remains chargeable including ‘hotel costs’ in care home placements
In Wales, the devolved administration has taken a number of tentative steps away from the (lack of) funding settlement in England. Following the 2007 extension of further devolved powers to the Welsh Assembly the government introduced the Social Care Charges (Wales) Measure 2010 that introduced a framework for charging for non-residential care, and a maximum weekly charge of £50. The Social Services and Wellbeing Act (Wales) 2014 superseded this shift, consolidating these changes and extending the powers of Welsh government to charge for a number of services (although not extending to children’s services). The government have since increased the non-residential charging cap to £70 per week, and increased the threshold free care in residential settings to £30,000 and £40,000 in April 2018, while the Labour administration has promised to increase it further to £50,000 by the end of the assembly period in 2021. Given the recent introduction of these changes there are no studies on the impact of the extension of free care in Wales.
In Northern Ireland, change has been slower in social care funding policy due to the historical integration of health and social services, as well as broader political uncertainty. The few reports there have been into the current state and suture of adult social care in Northern Ireland have either focused on further promoting integration within the Health and Care System, or on increasing cost-effectiveness. There were no proposals for a new statutory framework for Adult Social Care entitlements, apart from the recent expert Advisory Panel Report, ‘Power to People’ (Kelly and Kennedy, 2017) which calls for the rights of carers to be placed on a legal footing.
Across the globe, ageing societies are attempting to grapple with an increase in demand for care and insufficient funding to meet his demand. Funding reform in the UK, particularly in England (where social care reform remains the responsibility of the UK government) remains fundamentally political. Opposition parties have successively exploited lack of public knowledge about the current system, and fears about their future financial security and status of their homes and inheritances, despite the fact that many already lose home ownership under the current system. Several countries around the world have gone significantly further in legislating to provide sustainable social care funding. An example of progress in this area can be seen in Germany’s iterative approach to reform.
The German social and private long-term care insurance introduced in 1995 is a compulsory insurance to cover a portion of long-term care costs. For home care, entitled beneficiaries have a free choice between benefits in kind provided by professional nursing and personal assistance services and cash benefits for informal care. Benefits in cash and in kind can be combined and the long-term insurance also offers counselling when choosing the provider. In addition, benefits are provided for care in residential care homes and semi-residential facilities (e.g. day care). In 2017, about 3.3 million people received support from the long-term care insurance funds, and about 73% of these beneficiaries got long-term care at home. Between 2015 and 2017, Germany’s Federal cabinet passed the three ‘Acts to Strengthen Long-Term Care’. The Acts build on successive reforms since the establishment in 1995 of the German programme to provide universal support for the cost of long-term services and support though compulsory long-term care insurance.
Informal carers in Germany provide the bulk of care, as they do in other countries. Measures have been taken to secure pension and insurance contributions for those providing more than 10 hours of care at home. This ensures carers are able to access unemployment benefits (including support to become reemployed) if they decide to leave work in order to care for relatives. To support the Acts’ implementation, the ‘First Act to Strengthen Long-Term Care’ foresees a rise in contributions to the long-term care insurance and from 2017 an additional 5 billion Euros have been made available annually. With the new care grade 1, up to an additional 500 000 people will now get access to selected long-term care insurance benefits, making support available earlier to those who do not yet require personal care, but may benefit from care counselling and information and home adaptations.
4. Integration between health and care
People who use social care often use a number of other services, particularly community and acute healthcare. The NHS and local authorities who purchase and provide these services share a number of goals: keeping people well in their own homes for as long as possible, improving system efficacy and promoting a more person (or patient) centred approach. However, the experience of using a both services can often be fragmented, frustrating and sometimes detrimental to wellbeing. For instance, people often find themselves in hospital unnecessarily due to insufficient coordination between hospital discharge and local authority assessment processes. Integrating these services to provide a more coordinated service has been a key policy goal for UK governments for at least two decades.
There have been a number of different approaches to this challenge. These approaches include pooled funding, joint planning and purchasing of services as well as merging organisations, co-locating staff and centralising information systems. Miller et al (2016) describe a number of ways of thinking about integration, including the micro, meso and macro spectrum. Micro integration describes the interactions of practitioners, for instance domiciliary care workers and district nurses. Meso integration describes joint teams of practitioners from different silos or targeted services such as integrated discharge teams. Macro integration describes the systems-level integration at play in joint boards and shared policymaking across localities. Across the UK, recent integration policy has focused on macro-level changes: systems level funding and strategy for particular localities, with meso and micro initiatives greatly varying from area to area.
In 2013, The Better Care Fund was established in England, and sought to transform local health and care systems with a joint pot of money spent on shared priorities of the health and care systems. These local priorities are agreed and signed off at local Health and Wellbeing Boards: another macro integration intervention (enshrined in the 2012 Health and Social Care Act) to develop joint health and care strategy. The Care Act 2014 established a legal duty on local authorities to promote integrated services with local NHS bodies through Health and Wellbeing Boards (Heenan and Birrell 2018).
The NHS in England has also sought to develop new integrated organisational forms, influenced by developments in the US. In 2015, NHS England announced a range of pilots in order to explore organisational alignment between different aspect of health and social care services. These ‘vanguard sites’ sought to develop new models of care based on new contractual structures, payment regimes and joint organisations. Since 2015, these new organisations and partnerships have developed ‘place-based’ approaches: collaborations that seek to manage demand into acute and promote wellbeing and prevention of ill health. NHS England has sought to evolve these loose partnerships into ‘Sustainability and Transformation Partnerships’ and more recently into more formal ‘Integrated Care Organisations’.
Devolution policy, enacted in the late 1990’s by the Labour government and extended throughout the 2000’s by Coalition and Conservative governments, has enabled Scotland, Wales and Northern Ireland to pursue distinct policies on integration. The Health and Personal Social Services Order 1972 established joint Health and Social Care bodies in Northern Ireland, meaning services there have a long experience of one particular form of integration. However, Northern Ireland has also pursued further coordination of services (from the service user/patient perspective) through the establishment in 2014 of Integrated Care Partnerships (ICPs) which identify high intensity users and attempt to design ‘wrap around care’ led by clinicians. (House of Commons Library, 2017).
In Scotland, the government has taken a more direct legislative approach to integration. In 2014 it introduced the Public Bodies (Joint Working) (Scotland) Act 2014. The Act places a duty on NHS organisations and local government to delegate health and care functions and budgets to new integrated authorities, with a view to making these new authorities the joint commissioner of health and care.
In Wales, the structural division between health and social care has persisted as in England. In 2009, the Welsh government established Health Boards to coordinate health and social care across regions. In other ways, Welsh integration policy has mirrored English. In 2014, they established an Intermediate Care Fund that aimed at integration and focused on delayed hospital discharge. The 2014 Social Services and Wellbeing Act established a legal duty on local government to promote integration, and the Well-being of Future Generations Act in 2015 established Public Service Boards that are required to promote wellbeing across local areas (Heenan and Birrell 2018).
Across the four nations, there are persistent barriers to integration. Firstly, the historic structural distinction between health and social care prevents coordination of assessment: as social care, remains means and needs tested and the NHS is a universal, needs-based service. There remain professional conflicts between health and social care staff and there is a persistent difference in status between NHS and social care professionals. The initiatives we have described here have also been criticised for a number of reasons including focusing narrowly on hospital performance measures, lacking significant strategic influence from local government and failing to involve patients and service users. The goal of improving the coordination of care through individual and organisational collaboration is likely to continue, so initiatives to promote integration are likely to persist as features of the social care policy landscape.
5. Conclusion
As populations age and demand for social care rises, there are a number of issues which need to be addressed, including the best ways to deliver quality care for those who need it and the best ways to pay for that care. There are also broader challenges about how to invest in preventative and asset-based approaches that minimise people’s needs for formal care, and how to ensure that formal care services support informal family carers to stay in good mental and physical help. Many countries are facing this dilemma and some, such as Germany, have taken bold steps to address it. In the UK, the political debate seems stuck on issues on payment, with all different funding options rejected as not being fair to one group or another. Scotland has gone furthest in relation to reform by the provision of free personal care, but even in Scotland there has not been a move towards any kind of long-term insurance model to bring more money into the system.
A range of issues intersect with social care, and are looked at elsewhere in the handbook. Housing is a key issue, since appropriate housing can be a key way to sustain people’s independence and mobility. Technology is also an area of growing overlap with social care, as artificial intelligence offers new possibilities for a range of supports – from so-called ‘care robots’ to new communication technologies that can improve connectedness and reduce loneliness.
Social care has for years been described at a Cinderella service compared to the NHS – somewhat hidden and poorly funded. It has risen in political salience in recent years – fuelled in part by a number of scandals relating to abusive or inadequate care provision – but also due to the ageing of the so-called baby boomer generation whose expectations of care may be different to the war generation that preceded them. Calls for a care system that keeps people independent as long as possible, and provides high quality and affordable care when they need it will only get louder in the future.