Simon Bottery, Senior Fellow (Social Care) at the think tank, The King’s Fund, examines who is really absorbing the strain of an under‑resourced system — and why the pressure can no longer be ignored.
The publicly funded social care system is one large pressure relief valve. The system can’t cope with the demands placed on it by an ageing population, increased working age disability, rising costs and restrictions on spending. So, like a boiler that needs to reduce its pressure, it has found a range of ways to prevent it blowing up. Unfortunately, many of these methods simply displace the pressure – whether in costs or time – onto individuals, families, providers and the workforce.
Individuals face additional costs and reduced services. Many are shut out of the publicly funded system entirely, either because their needs are regarded as too low or because they are judged to have savings that disqualify them from state support. As a result, they have to pay all their costs themselves. The Office for National Statistics estimates that just under a quarter of home care users and over a third of residential care users are self-funders.
Those that can’t afford to pay or choose not to have a stark choice: rely on family and friends or go without care entirely. Those who choose to pay will be hit by a further injustice – they will typically pay 40% more for their care to subsidise the low fees paid by local authorities for publicly-funded care. But even those who manage to get into the state-funded system have to pay for the privilege. Most will have to pay towards the costs of their care and in 2023/24, local authorities raised £4.1 billion from individuals in fees and charges.
As well as individuals, families often have to cope with some of the pressure themselves. They are often required to provide significant amounts of unpaid care to supplement anything that a person gets from the state-funded system. There are 4.7 million unpaid carers in England and 1.4 million of them provide more than 50 hours of care a week.
Some families also have to provide not just time but money. One of the hidden surcharges of the state funded system are ‘top up’ fees paid by families to supplement the fees paid by local authorities for the residential care provided to their relatives. In theory, these are supposed to cover just added extras like a better room but in practice many families have to pay them just to get a decent standard of care for their loved one. There has never been a reliable estimate of the percentage of families who contribute in this way or the amount they pay, though a report in 2013 estimated 56,000 families were paying them.
Care providers also have to relieve some of the pressure on the social care system. They will often have to compromise on the quality of care they would like to provide in order to deliver it within the fee rates paid by local authorities. Even then, as we have seen, they will often need to subsidise care with higher self-funder rates. Some providers will decide to quit the market entirely or be forced out of business, particularly if they are largely reliant on local authority rates.
Finally, of course, the workforce bears some of the pressure of an under-resourced system. Low fees mean low wages, with 23% of care workers paid at around the minimum wage. With persistently high vacancy rates, some staff also experience burnout from working too hard for too long, and ‘moral injury’ from not being able to care in the way they would like – for example by having to rush homecare visits when someone is in need of company.
There have always been pressures in the social care system but our ‘360’ analysis of the sector shows arguably they have never been higher, while public satisfaction is at its lowest ever. The job of the Casey Commission is not just to relieve the pressure with some minor adjustments but to recommend wholesale change that will bring the whole system back into balance. Then, the government must act.
