‘What do we do with a
problem like social care?’
Professor Guy Daly
Coventry University
Making Research Count Seminar
Kings College London
11 April 2017
Introduction
• Context
• ‘Crisis’
• A brief history of adult social care from a sociopolitical perspective
• Solutions
– Integration
– Social movements
– Choice
– Social insurance and funding
CONTEXT
• Demography
– Ageing society
– Inequalities within and across age groups
• Mortality
– Improved life expectancy
• Morbidity
– co-morbidities
– Active ageing
– Upstream prevention
• Societal expectations
– Empowered/consumers
– Evidence that increased levels of control / dignity and satisfaction
levels
• Budgets/funding
‘Crisis’ in health and social care
• NHS
– funding & budgets
– workforce
– challenges: mid-staffs/Francis
– expectations
• Social care funding (means and need)
• Workforce challenges in both health and
social care
Yet health care (and public
health) a great success
• Commonwealth Fund 2014 research
• improvements in mortality and morbidity
• BUT inequalities in health persist
– Service area
– Geographically
– Demographically
• Age
• Ethnicity
• Class
Social care less so …?
•
•
•
•
increasingly only the most needy
Winterbourne View
Market failure – Southern Cross
10 fold difference in use of residential
care across UK
• no residential care in London because
no one can afford it
… social care less so?
• LA social care – 1/3rd of LAs have seen increases,
1/3rd a cut
• even with 2% c tax increase (if all local authorities
increased by 2% over next 4years, still £4bn short;
• residential care for older people (nursing and res
care)
– many / most die within 0.5-2 years;
– 0.25 recover and leave the nursing home to go
home
– so, getting it wrong for 0.75??
So how did we get here?
• casting and recasting of social policy discourse
• Margaret Thatcher’s - ‘there is no such thing as
society, only individuals and their families’
• John Major’s promotion of citizen’s charters, and
where to put the apostrophe (!)
• Tony Blair’s ‘something for something’ society, in
which ‘the rights we enjoy reflect the duties we owe’
• Gordon Brown’s A National Care Service
• David Cameron, and the desire to replace ‘Big
Government’ with the ‘Big Society’as well as ‘we’re
all in it together’ austerity
The Blackpool Rock of ‘Choice’
 consistent promotion of choice over last 35
years
 and / or markets more generally
 in the organisation and delivery of welfare
 Including social care policy
 from the NHS&CCA 1990
 to Caring for our future: reforming care and
support 2012 to The Care Act 2014 (and 2020!)
 to improve governance and accountability
 to improve services, responsiveness to users
Social Care Policy
• 1946 NHS Act & 1948 National Assistance
Act
• Crisis of funding in the 1980s
– ‘perverse incentives’
• 1990 NHS and Community Care Act
– Empowering community care users
Social Care – New Labour
•
New Labour’s adult social care policy
– Royal Commission on Funding (1999)
– continuity with the Conservatives
• independence
• user involvement
• support for carers
• social (not health) care is open to means testing and rationing
• a mixed economy of provision
• care provided via (quasi-)markets
• Personalisation and choice
– IBs, PBs, SDS
– 2010 Gordon Brown’s National Care Service …..
Social Care – the Coalition and
Conservative Governments
 Continued roll out of IBs, PBs, DPs and
 Crisis of funding
 Dilnott Review (2011-12)
Commission on Funding on Care and Support
•
White Paper (HMG, 2012) - Caring for our future: reforming care
and support and Care Act 2014
– promote independence & wellbeing
– greater national consistency in access to care
– provide better information to help choices
– more control
– improve support for carers
– improve the quality of care and support
– improve integration
•
•
•
•
Care Act 2014
Postponement to 2020
Cap on individuals’ expenditure
Overall (individual and LA) expenditure
capped at £72,000 – subject to inflationary
increases
• Better Care Fund
• 2% Council Tax for social care
Current Government
• Continued with the social care precept
– Increased to 3%
– Special arrangements for Surrey CC
• Sustainability Transformation Plans /
Partnerships
– 5YFV – mid-term review
• ‘Bed-blocking’ v integration
• Social care Autumn 2017 Green Paper?
Potential additional resources for adult social
services, £ millions (2016–17 prices)
IFS https://www.ifs.org.uk/publications/8811
Policy measure
2016–17
2017–18
2018–19
2019–20
382
793
1,221
1,668
0
104
796
1,421
382
897
2,017
3,089
382
999
1646
1,662
0
104
796
1,421
0
75
0
0
382
1,178
2442
3,083
0
281
425
-6
Original plans
(1)
Social Care
Precept
(2)
Improved
Better Care Fund
(3)
Total
New plans
(4)
Social Care
Precept
(5)
Improved
Better Care Fund
(6)
Other extra
grant funding
(7)
Total
Total extra funding
under new plans ((7)
minus (3))
State of Social Care now
 social care markets mixed economy of providers has occurred
 substantial shift to independent sector
 little LA/public sector provision
 but independent providers are struggling
 shift to home care
 numbers of LA funded users decreases year on year
 only those most in need receive LA funded support
 paradoxically, these individuals have received more hours
of care and more bespoke care
 Non publically funded users increasingly resorting to self
funding
Types of care
• Formal care – paid for
– Publicly funded
– Privately funded
• Informal care – provided by relatives
• Publicly funded/informal care = help with ADL
= washing, dressing
• Privately funded = help with shopping and
housework [despite choice agenda?]
Prevalence of social care
• Less than 1% of GDP is spent on social care
• Funding gap estimated to be £1.9 billion in 2017–18
• 26% less 65s and over receive some social care to
assist ADL over last six years
– 23%from an informal provider (e.g. spouse, child)
– 9% receive formal care
– 6% receive both formal and informal
• Only 36% who receive formal care will get 5 or more
hours care a week [9% of all 65s and over]
• Only 2% of individuals were paying for or contributing
to home care costs
(see Barker Review/Nuffield/Health Foundation/Kings Fund)
Reasons for regional variation
• Social care is means tested and needs tested
locally
• LAs have variable incomes – so have more or
less to spend on social care
• Variable expenditure
• Application of eligibility criteria are variable –
doing more than the minimum?
• Continuing health care variable allocations
• Self funding variations
The solutions?
•
•
•
•
Integration
Social movements
Choice and personalisation
Socially insured social care
Integration the answer?
• Very complicated health and
social care system currently
• Tackle bed blocking
• Various examples - NI, Torbay,
Dorset, etc.
…integration the answer?
• Work of Jon Glasby
• Unhelpful disruption of reorganisizations
• Have to deal with health and social care
divide – the 1944/46/48 legislation
• More efficient, effective, efficacious?
• It certainly would help….
• Governance
– role for local authorities or combined
authorities
Social movements/social assets
the answer?
•
•
•
•
•
•
•
Communities doing it for themselves
Shared Priorities
LinkAge Plus
Marmot cities – Coventry
Capacity?
Social isolation
Fit with late-modernity?
Choice the answer?
•
•
•
•
£3k per pregnancy maternity care…
do we want choice?
empowered users – GP daughters …
is choice efficient – supermarkets
offering less choice and now more
profitable…
• is it a distraction?
• some users do, others don’t
Problemetising and critiquing the
choice & market discourse




economic
environmental
psychological
socio-political
Why we need to manage social care
markets….
 market choice results in efficient production &
distribution of goods?
 price will keep supply and demand in balance
 Problems:
 the need for perfect information
 how to distribute scarce goods
 how to distribute merit and public goods
 problems of inelasticity of supply
Adequate funding the answer?
•
•
•
•
A socially insured social care system?
Sharing risk
Ironing out the unpredictabilities
Greater certainty for all stakeholders
Social Care – Dilnott Review (1)
Main proposals:
• a national system of assessment and eligibility to end the
postcode lottery
• a £35,000 cap on lifetime contribution to adult social care costs
• a rise from £23,250 to £100,000 in the means-test savings
threshold
• lower caps on the lifetime costs for people who acquire needs
at earlier ages
– free care for under 40 year olds for their lifetime
• a £7,000-£10,000 max p.a. for board and lodging costs of
residential care
Social Care Dilnott Review (2)
• Implications:
– initial £1.7 billion in additional public expenditure
(0.14% GDP) if cap on individual contributions set at
£35,000
– rising to £3.6 billion (0.22% GDP) by 2025/26
– max individual spend - 30% of assets to fund care
• Funding:
– changes to tax relief and NI contributions
– estate tax or care duty
– development of social care insurance
Solutions: Kings Fund 2014 Barker Commission on the
Future of Health and Social Care in England
•
•
•
Joint commissioning of health
and social care
Increase provision for ‘free’
social care
– Make all social care for
those with ‘critical’ needs
free at the point of use.
– Extend this to ‘substantial’
social care needs as the
economy improves.
– By 2025, provide support for
‘moderate’ needs as well.
Greater choice and integration
Government should assume that public spending on
health and social care will increase from 9.6% to
11–12% by 2025
Fund by increases in public expenditure funded by
• increased contributions from those able to – prescription charges,
• NI
• reducing wealthier older people’s allowances (winter fuel, TV, etc.)
• wealth and property taxes
Conclusions
 stop fetishising about
 choice in social care and elsewhere
 Integration
 Sovereign heroic consumer users
 (re-)establish a socially insured social care
system
References
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1 Commonwealth Fund (2014) US Health System Ranks Last Among Eleven Countries on
Measures of Access, Equity, Quality, Efficiency, and Healthy Lives,
http://www.commonwealthfund.org/publications/press-releases/2014/jun/us-health-systemranks-last
2 Crawford, R. and Stoye, G. (2017) The prevalence and dynamics of social care receipt,
Institute for Fiscal Studies, London: IFS
3 Daly, G. (2009) ‘LinkAge Plus: The Benefits for Older People’, London: UK HMG –
Department of Work and Pensions
4 Daly, G. (2012) ‘Citizenship, choice and care: an examination of the promotion of choice in
the provision of adult social care’, Research, Policy and Planning, 29 (2), 179-190
5 Glasby, J. and Daly, G. (2014) ‘Adult Health and Social Care’, in (eds.) Bochel, H. and
Daly, G. (2014) Social Policy, London: Routledge
6 Lodge, C., Carnell, E. and Coleman, M. (2016) The New Age of Ageing, Bristol: Policy
Press
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8 Humphries, R., Thorlby, R., Holder, H., Hall, P. and Charles, A. (2016) Social Care for
Older People – Home Truths, Kings Fund, London, Kings Fund
9 Johnston, L., Rozansky, D., Dorrans, S., Dussin, L. and Barker, T. (2017) Integration
2020: Scoping research, Social Care Institute for Excellence, London: SCIE
10 Phillips, D. and Simpson, P. (2017) National standards, local risks: the geography of
local authority funded social care, 2009–10 to 2015–16, R128 - Institute for Fiscal Studies,
London: IFS
11 West, K. (2014) ‘Older People, Population Ageing, and Policy Responses, in (eds.)
Bochel, H. and Daly, G. (2014) Social Policy, London: Routledge
12 WHO (2016) Global strategy and action plan on ageing and health (2016-2020),
http://www.who.int/ageing/global-strategy
13 Woolham, J., Daly, G., Sparkes, T., Ritters, K. and Steils, N. (2016) ‘Do direct payments
improve outcomes for older people who receive social care?’, Age and Society, Vol. , pp. 124