In March 1999, the Royal Commission on Long Term Care reported. It was critical of the prevailing system of funding social care, saying that “doing nothing with respect to the current system is not an option”.
Almost 20 years on, following countless further reviews and reports, doing nothing has been the prevailing option. This Autumn the government is due to publish a green paper setting out its plans for the future of social care. Will this finally be the moment when doing nothing genuinely ceases to be an option?
How the status quo system has been so enduring is at face value perplexing – the current social care system is almost universally seen as unfair. Much of the Royal Commission’s critique is as valid today: it is too complex and provides no clarity as to what people can expect; it too often results in people moving into residential care when this might not be the best outcome; help is available to the poorest but the system leads to impoverishment of people with moderate assets; there is a degree of fear about the system which is of concern in a modern welfare state; it is riddled with inefficiencies; the time has come for it to be properly modernised.
The difference today, which makes continuing to muddle along such a damaging option, is that help is often not even available to the poorest. Over the last 20 years, demands on the social care system have continued to increase, reflecting the ageing of the population. But one of the key developments has been the growing need for care for working-age adults as prospects have been transformed for those born with physical or learning disabilities or who have fallen ill or been injured.
As demand has grown, funding has failed to keep pace. As shown in the following chart, social care budgets were not protected from austerity and spending in 2016/17 was 10% lower in real terms than in 2009/10.
Source: Spend data for England, Health Foundation analysis of NHS Digital: Personal Social Services: Expenditure and Unit Costs, England
Local government has been caught between a rock and a hard place. The Office for National Statistics report little improvement in adult social care productivity over this decade and balancing the budget has meant restricting eligibility and bearing down on the unit prices paid to providers. An analysis of official statistics by Age UK this summer found that around 1.4 million people over 65 now have some level of unmet need with tasks such as getting up, washed and dressed. The Competition and Markets Authority reviewed the care home market in 2016 and found that the fees currently paid by local authorities are not sufficient to sustain levels of care under the current funding model. They were on average, as much as 10% below the cost of care. In the past, publicly funded social care has in effect been ‘subsidised’ by higher payments from those who self-pay.
The Royal Commission noted that reforming social care was a complex issue and that none of the options were easy. Recent research by the Health Foundation and Kings Fund shows that almost 20 years on the hurdles for reform are still great. All options are expensive and the public has little understanding of social care. Most assume that the current system is more generous than it actually is, with many believing that social care will be free when they need it. Unreformed social care will still need significant additional resource as further squeezes on eligibility and provider fees become unfeasible. Sustaining the current system is no longer a viable option and it may not even be the easiest one.