Simon Bottery Kings Fund
In November 2019, we identified the eight key pr in adult social care that the incoming government – then led by Boris Johnson – would need to address if it were serious about ‘fixing’ social care.
Initially, the government advanced towards addressing these with a series of proposed reforms, including the introduction of a cap on lifetime care costs, changes to the means test and a White Paper on wider reforms. We welcomed these changes, though said they did not go nearly far enough.
However in recent months – and following two changes of prime minister – reform has entirely stalled. In its November 2022 Autumn Statement, the government announced that the cap and means test reforms would be postponed until October 2025. With a general election to be held no later than January 2025, there is therefore a significant risk that these reforms are never implemented.
Now, following publication of its ‘next steps document on 4 April 2023, many of the remaining measures from the White Paper have been cut back or even abandoned. Most notably, a key promise of at least £500 million to be spent on workforce training, qualifications and wellbeing has been cut to £250 million, and a promised £300 million to transform housing options has been replaced by £102 million for smaller in-home adaptations. Spending on innovation and improvement has also been cut back, though investment in digital has emerged largely untouched and there are very small pots for carer support, international recruitment and volunteers.
This reduction in spending is particularly disappointing because it comes at a time we welcomed these changes, though said they did not go nearly far enough.
However in recent months – and following two changes of prime minister – reform has entirely stalled. In its November 2022 Autumn Statement, the government announced that the cap and means test reforms would be postponed until October 2025. With a general election to be held no later than January 2025, there is therefore a significant risk that these reforms are never implemented.
Now, following publication of its next steps document on 4 April 2023, many of the remaining measures from the White Paper have been cut back or even abandoned. Most notably, a key promise of at least £500 million to be spent on workforce training, qualifications and wellbeing has been cut to £250 million, and a promised £300 million to transform housing options has been replaced by £102 million for smaller in-home adaptations. Spending on innovation and improvement has also been cut back, though investment in digital has emerged largely untouched and there are very small pots for carer support, international recruitment and volunteers.
This reduction in spending is particularly disappointing because it comes at a time when all the trends on adult social care are going in the wrong way going in the wrong direction more people are asking for support but fewer are getting it; workforce vacancies are at an all-time high and public satisfaction with social care is at its lowest ever.
Here, sadly, we update our initial assessment of the government’s reform programme.
What’s the problem? What has the government done? How effective is that response? What’s the score?
Means testing Adult social care has a stringent means test that restricts access to services. Its plans to make the means test more generous have been postponed to 2025, which may mean they are never implemented. Delayed. The delay puts in doubt changes that would bring 40–50,000 more people into the state-funded system each year, after a decade in which the means test became tighter in real terms. Even if the changes are introduced in October 2025, social care will remain much less accessible than a free-at-point-of-use NHS. Our rating in May 2022 was 7/10.
Our new rating is 3/10.
Catastrophic costs Many people who have to pay for their own care end up paying more than £100,000 over their lifetime. Its plans to introduce a cap of £86,000 on lifetime care costs has been postponed to October 2025, which may mean it is never implemented. Disappointing and delayed. The cap was already much less generous than expected- those with assets of less than £106,000 would get very little protection from it – and now has been delayed for two years. Our rating in May 2022 was 5/10.
Our new rating is 2/10.
Unmet need Around 1.6 million older people, and an unknown number of working age adults don’t get the support they need. Relatively few of the estimated 4.5 million unpaid family carers in England receive local authority support. The changes to means test (see above) that would bring more people into the state system have been postponed to October 2025. Only £25 million has been allocated to ‘kickstart a change in services’ for carers Very limited. Even with the changes to the means test, now delayed, people would still have to get past a very strict needs test if they were to access publicly funded care. This has, in practice, been getting stricter over the years as local authority budgets struggle to keep pace with increased demand. Our rating in May 2022 was 2/10.
Our new rating is 2/10.
Quality of care There is basic concern among the public about quality, illustrated by 15-minute care visits in home care but extending to fears of abuse and neglect in care homes. There are plans to trial and scale innovative approaches to quality care and improve strengths-based assessments. There is also funding for continued investment in digitising the social care sector. There is £102 million to support home adaptations but this has replaced a £300 million fund to increase housing choice. Limited. These reforms add up to only £325 million, which is unlikely to make a significant difference against a background of £26 billion spent every year on publicly funded adult social care. The one coherent area of reform is digital, where the government has credible plans and funding has largely been retained. Our rating in May 2022 was 4/10.
Our new rating is 3/10.
Postcode lottery Access to social care varies depending on where people live and, while some of this variation is a reasonable response to differing needs, some of it is not. The Health and Care Act gives the Care Quality Commission powers to audit local authorities’ delivery of adult social care. Formal assessments will start in September 2023 and all local authorities will have been assessed by autumn 2025. Potentially valuable. It is a welcome move, but it is not yet clear what impact it will have, particularly in light of financial difficulties facing local authorities’ provision of adult social care. Our rating in May 2022 was ‘too soon to say’
Our new rating is ‘still too soon to say’
Workforce There aren’t enough staff in adult social care and most observers believe that better pay is the critical factor in recruiting more. The government has cut to £250 million a fund for workforce training and development, and there is £15 million short-term funding to support international recruitment. Severely limited. This is a major cut from the initially promised £500 million. The government is providing some short-term money to shore up recruitment and retention but there is no plan for resolving the big issue of pay. Our rating in May 2022 was 2/10.
Our new rating is 1/10.
Market fragility Some social care providers hand back contracts or go out of business entirely because the rates paid by local authorities for care are too low. The government has provided financial support to councils to carry out ‘fair cost of care’ reviews, and ‘move towards’ paying higher fees but funding for this has largely been redirected just to keep the sector afloat. Very limited. The ‘fair cost of care’ would have been a major intervention in a failing market but there is too little financial support on offer and the initiative could even destabilise the sector further by raising expectations that local authorities cannot afford to meet. Our rating in May 2022 was ‘too soon to say’
Our new rating is 3/10.
Disjointed care Different parts of the health and care system are not working together to deliver care effectively. From July 2022, England has 42 integrated care systems (ICSs), which aim to join up health, care and other services Potentially important. The ambition to plan and deliver joined-up services to improve the health and wellbeing of people in their area is a critical one. However, there are fears that underfunded social care will lack influence over NHS-dominated structures. Our rating in May 2022 was 6/10.
Our new rating is 6/10. Much continues to depend on how the reforms are implemented within each ICS.