The future of social care in England

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3384 (Published 01 September 2009) Cite this as: BMJ 2009;339:b3384
  1. Christina R Victor, professor of gerontology and health services research
  1. 1School of Health and Social Care, University of Reading, Reading RG6 1HY
  1. c.r.victor{at}reading.ac.uk

    A national service that aims to reduce variability in access and availability

    The green paper on the future of social care for adults was published on 14 July 2009.1 The purpose of Shaping the Future of Care Together is to debate the options for the future funding of social care and support for two key groups of vulnerable adults: older people and younger people with disabilities. In both groups the numbers in need of care are substantial and predicted to increase.1 About 2.45 million older people have some social care needs,2 and 1.2 million receive some publicly provided social care services.3

    At the heart of the debate is the distinction, enshrined in the initial structure of the post war welfare state, between healthcare needs and social care needs and how these should be met. Health needs are the province of the NHS, funded mainly from general taxation within the broad structure of a national system that is committed to equitable quality and access to care. Social care needs were conceptualised as separate. Local authorities administer the system and organise the nature and extent of social care in response to local needs, and they are authorised to charge whatever is deemed appropriate.4 5 6

    Analysis of different forms of welfare provision internationally shows that medical care is seen to merit special consideration, with care provided free, or with users having to pay only a modest contribution.7 Even in the United States, where health care may be construed as closest to consumer goods, some aspects of the system show the special status of medical care, such as the Medicare programme for older people. This contrasts with social care, which has no special status, and where the types of tasks involved—such as personal care, preparation of meals, or care of the house—are part of normal daily life and services that we might be expected to pay for ourselves. Indeed, social care is often represented as an area of personal responsibility, in contrast to the more collective responsibility ascribed to medical care. However, these tasks are important in enabling older people to continue to live at home independently.8

    It has always been presumed that people should contribute towards their social care, in the United Kingdom and other countries, although the size of the contribution may vary. Thus there is an increasing distinction between the provision of health care and social care based not just on how needs are defined and met, but also on how they are paid for. An example of this tension is the funding of long term care.9 Social care is means tested in England, and anyone with assets worth more than £23 500 (€27 300; $38 500) who needs to go into a care home receives no help from the state. Thus, older people and their families can face huge bills for care. The cost of a care home is about £24 000 a year and that of a nursing home is £35 000.10 Older people (and their families) spend around £5.9bn on social care, a figure that matches state funding.10 Under the current system, some people have to pay as much as £200 000 for social care, whereas others receive it free.1

    In response to what is termed the “postcode” social care lottery, the green paper proposes a national social care service to tackle this variability in service provision and charging. At the heart of this are the proposals for the future funding of social care and three national policy options, two of which explicitly include some state support for social care. Specifically excluded are both fully funded state care (too expensive) and making people entirely responsible for their social care arrangements (too many people would be unable to afford such care). In two of the proposals the state would contribute a quarter to a third of social care costs, with people taking out insurance at a cost of £20 000-25 000 to cover the remaining costs, or paying themselves, with help for those on low income. The third option is compulsory insurance against the need for social care.

    These are important proposals that will shape the future of the provision of social care for future generations of vulnerable adults. They mark a shift away from the inherent variability of the social care system towards a nationally based social care system, relating to England in the first instance. This is an important debate that is currently open to public consultation until 13 November (http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_102339).


    Cite this as: BMJ 2009;339:b3384


    • Competing interests: None declared.

    • Provenance and peer review: Commissioned; not externally peer reviewed.


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