Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: What the plan for social care omitted

BMJ 2021; 374 doi: (Published 10 September 2021) Cite this as: BMJ 2021;374:n2227
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter @mancunianmedic

Standing on the steps of Downing Street as he took office as UK prime minister in July 2019, Boris Johnson promised to “fix the crisis in social care, once and for all, with a clear plan . . . to give every older person the dignity and security they deserve.” He reiterated this pledge in his Queen’s speech that October, promising to “bring forward proposals to reform adult social care in England.”12

Finally, this week, on 7 September 2021, Johnson announced Building Back Better, the plan for health and social care in England.3 This focused far more on reducing the NHS backlog after covid-19 than on adult social care itself, but it was approved by a House of Commons majority on 8 September.4

For a plan that was two years in the making, the details fall well short of what’s been promised and are notable for what they omit as much as what they include. Despite exhortations from experts in this area of public policy for a broader, reforming vision—encompassing prevention, independence, and communities, not just a reductive focus on how to fund payments for care homes and statutory personal care—the announcement was all about the money. A new “health and social care levy” was announced, starting from April 2022, in the form of a 1.25% increase in national insurance contributions from working age employees.

Back in 2011, the Dilnot Commission on social care funding proposed a cap on costs for people paying for their care from their own assets.5 Its implementation was stopped by the Conservative government in 2015.6 But the issue of protecting people from selling their homes or using their savings or pensions to pay for care has remained a political and media hot potato ever since.

As the new plan is for both health and social care, the government was explicit that the priority in the first phase of the new funding would be helping the NHS to deal with post-covid backlogs of elective work, capital expenditure, and a pay increase for healthcare staff. Only £5.6bn (€6.56bn; $7.77bn) of the forecast £36bn extra revenue over three years was promised for social care—only a sixth of the money. That amounts to £1.8bn a year, which falls short of the Health Foundation’s estimate of £6bn a year needed to tackle the current gap in social care funding.7

Sajid Javid, secretary of state for health and social care, was cagey about whether the social care element would increase after 2025.8 But history teaches us that the high visibility and greater political sensitivity of the NHS, and the public’s greater contact with it, mean that it always wins any battle for resources. Any increase in the number of people receiving social care to reflect the growing demographic demand will be left to local government to fund, through efficiencies and local tax rises.

Adult social care remains heavily rationed by tight eligibility criteria. Even support needs that are classified as “moderate,” let alone “substantial,” include very significant physical or cognitive impairment.9 There is no plan to take this level of need out of means testing and personal payment, as proposed by the Barker Commission in 2015.10 There are no proposals to tackle the variable quality of care provided by a multiplicity of contractors or to make the system easier to navigate for people needing support.

Neither are there plans for greater use of personal care budgets and direct payments that might be valued by disabled people of working age, who account for around half of social care spending despite the public focus on older people.11 Nor any guarantees to honour the entitlements to assessment and support for unpaid carers (usually family members) set out in the Care Act 2014—despite most personal care still being provided by that army of millions of carers.

Most importantly, while the government’s plan does discuss greater professional development and career support for social care workers, backed by a £500m investment and a workforce white paper, it contains no credible plans to tackle gaps in the social care workforce.

At least one in 10 social care vacancies was unfilled even before the pandemic,12 and the crisis is more pressing now.13 The government’s point based immigration system explicitly excluded social care staff from the “key worker” group, instead suggesting that their largely private contractor employers should improve their terms and conditions rather than rely on immigration, which accounted for around one in five of the workforce by 2019.14

Despite the grand promises, the plan for adult social care is threadbare, focusing almost exclusively on funding mechanisms and personal financial protection. It’s a million miles from “solving the crisis, once and for all” or ensuring that all older people get “the dignity and security they deserve.”