Adult social care in England: more disappointment, delay, and distraction

Two years ago the prime minister, Boris Johnson, promised, “We will fix the crisis in social care once and for all with a clear plan we have prepared.”1 Unfortunately the resulting policy paper2 isn’t very clear, isn’t really a plan, and won’t fix very much.

This may not surprise many people who draw on care and support in England or people working in social care, who have been waiting decades for meaningful funding reform. At least 12 major reviews, visions, and white or green papers have emerged since the 1990s,3 and policy makers have failed to fully implement the funding proposals in any of them. Typically, successive governments start exploring major reform, only to stall, delay, or quietly abandon the idea when it seems too difficult to resolve.

Everyone agrees that there isn’t enough money to meet the needs of an ageing society with an increasing prevalence of multiple long term conditions, and the pandemic has highlighted the tragic neglect and fragmentation of the sector even more starkly than before.4 Alongside these long term trends, is a “lost decade” (2010-20) when widespread cuts to local government funding caused adult social care reform not merely to stall but to go backwards. Entirely predictably, this led to increasing unmet need, growing concerns about care quality, and growing pressure on family carers, social care staff, service providers, and partner agencies, with almost daily warnings that the system may long since have passed breaking point.5

Unfortunately, much of the debate has focused on care home funding (essentially a debate about inheritance). Currently, people moving into a care home in England pay for all their care if their assets are more than £23 250 (€27 000; $32 000).6 Home owners must therefore sell up to pay for care or place a charge on their property to be collected after their death. Support is effectively denied to everyone until assets are almost entirely depleted—one of the most severe and cruel cliff edges in our welfare state.

Many of the recent proposals are not new—they were initially put forward by the Dilnot Commission in 20117 and introduced under the 2014 Care Act but never implemented. From October 2023, state contributions will begin once someone’s assets fall below £100 000, with the state paying in full when assets reach £20 000. People will pay costs up to a maximum of £86 000—so there is both a floor and a ceiling to care home costs. However, it looks as if the £86 000 will include only the cost of direct care and people might still pay substantial sums for housing and living costs.

Care homes often charge one rate for council funded residents and around 40% more for residents funding their own care, using the self-funders to cross-subsidise the funded. Under the new proposals, self-funders will be able to ask their local authority to arrange care so that they benefit from better rates. All this will be funded through increased national insurance initially, and then by a new health and social care levy, but the extra revenue will be used to reduce the NHS covid-19 backlog as well as for the social care pledges. Over three years, the planned tax rises might raise £36bn, with only £5.4bn going to social care (and around half this paying for the cap on care costs). Social care seems likely to continue to lose out to the NHS in subsequent years.8