Social care: a summary of the framework and BGS's policy engagement
This update for our members provides information on the current position and BGS’s work in this area. It covers:
- why and how BGS is engaging in policy and influencing work on social care
- the legal and funding framework for social care and how it plays out in practice
- the charging framework for social care
It also includes some historical context and wider reflections, and the references used provide sources of further reading.
BGS’s engagement in policy and influencing work on social care
The health implications for older people when they are in need of, but not receiving, support with everyday tasks such as washing, dressing, and eating are only too familiar: the increased risks of a health crisis and an unplanned admission to an acute hospital; repeated readmissions, difficulties with discharge from hospital … the interdependencies between social care and health are clear. This is why one of BGS’s strategic objectives in our 2017-20 strategic plan is to, ”Continue to increase our influence with policy makers and policy influencers with respect to health and social care policy for older people across the UK” .
There are few signs of any quick wins which makes it all the more critical that we promote our position on social care as effectively as possible. In summary, our position is that financial investment is urgently needed, and that long term reform of the system is essential – and we explain the health impacts on older people and the work of BGS members that inform our position. We engage with the social care agenda in a range of ways, for example by: submitting and presenting written and oral evidence to consultations and Inquiries, and participating in high level meetings and debates, attending events and engaging with senior opinion-formers and decision-makers such as All Party Parliamentary Groups. We also collaborate with other charities; earlier this year we provided the clinical voice to support media work by the British Red Cross when they published their report, In and Out of Hospital, which looked at repeated admissions and the difference a volunteer can make by accompanying an older person when they are admitted to, and discharged, from hospital.
We were very pleased when, at the end of last year, our President, Dr Eileen Burns, was invited to join the Expert Advisory Group on the Green Paper on Social Care. It is to Eileen and BGS’s credit that Eileen was the only clinician invited to join the group. At the outset expectations of what a Green Paper might deliver were high. Disappointingly the indications now are that even if a Green Paper is published in the autumn (the publication date was put back from ‘before summer recess’), it is likely to be modest in its scope.
In order to shed light on why any reforms of the current system are so challenging I have provided some information on the funding, legal and charging frameworks for social care.
The funding framework
While overall responsibility for delivery of healthcare is national, responsibility for social care is local. This means it is down to individual local authorities to ensure delivery of the care they are legally obliged to provide to disabled and older people.
Unlike health, social care is not universally free of charge and there is no national budget allocation for social care. Funding from central to local government is not ring-fenced for social care. Local authorities’ main sources of funding are from council tax, business rates and their annual spending settlement from central government. From that they have to find the funds for social care for everyone who is entitled to it.
In 2015 the concept of a social care ‘precept’ was introduced which gave local authorities the power to increase council tax by an additional amount if the funds generated by the increase are ‘earmarked’ for social care (note the word ‘earmarked’ which is a much weaker requirement than ring-fencing income).
In practice, this means that local authorities struggle to fund basic social care. The struggle has been exacerbated by an increase in demand and years of cuts in real terms in the funding settlement from central government to local authorities. The consequence for older people is a tightening of the eligibility criteria for accessing social care. If the current model of funding and care remains unchanged, the funding shortfall is predicted to increase to a minimum of £1.5bn by 2020/21 and £6billion by £2030/31
The legal framework
The law that underpins the statutory responsibilities for social care is the Care Act 2014. It was introduced in order to simplify and make fairer the legal entitlements to care and support, which were covered under a number of different pieces of legislation. Its focus is on preventing and delaying needs for care and support. Nine pieces of legislation were replaced by the Care Act (Figure 1).
The Care Act 2014 also placed some new duties on local authorities. These are briefly summarised in Government guidance which states that:
The Care Act introduced some new functions, with the intention of ensuring that people
- receive services that prevent their care needs from becoming more serious, or delay the impact of their needs
- can get the information and advice they need to make good decisions about care and support
- have a range of provision of high quality, appropriate service to choose from
It goes on to say that local authorities must provide or arrange services that help prevent people developing needs for care and support or delay people deteriorating such that they would need ongoing care and support.
Charging and paying for social care
Unlike healthcare, social care is not universally free.
However there are low levels of awareness and understanding of this among the general public, and this is one of the challenges for any government in introducing changes to the current system. The difference between health and social care, and the charging system for social care provided at home or in a residential home, are poorly understood. Recent polling by Ipsos MORI provides clear evidence of the public’s lack of knowledge of the social care system. In particular they found very low awareness of how social care is funded, and just 12 per cent of the public thought that the individual pays.
Care provided at home is means-tested but the value of a person’s home is not taken into account. If they have more than £23,250 savings they have to pay for social care in full for however long they need it. If someone’s savings are below £23,250 and they are assessed as needing social care, generally, their local authority will pay for some of it and the individual will pay a top up fee. Once a person’s savings have gone down to £14,250 they will not be charged for care.
When it comes to paying for care provided in a care home the means test takes into account the value of an individual’s home as well as their savings (if their partner or spouse is not still living in the home). At present there is no upper cap on the amount someone can pay for social care. So the current system means that if you are a home-owner with savings of £23,250 and above, you face a potential loss of all your savings, and the value of your home too, if you are in need of care for a significant period of time.
Are there any exceptions?
Well, not really, unless you live in Scotland, where personal care is not charged for (in Northern Ireland responsibility for health and social care are integrated but the charging regime for social care is the same as for England and Wales).
Some history and some reflections
The lack of integration between health and social care and the concept of charging for social care has a long history. In the 19th century basic health care was provided for under the Poor Laws but other care had to be paid for by local authorities (think workhouses). The National Assistance Act 1946 which was implemented in 1948 required local authorities to provide accommodation for older people in need, delivered primarily through charitable and private organisations which they could inspect. It finally did away with the Poor laws and at the same time made clear that care which wasn’t health care, was the responsibility of local authorities. So the roots of the current system of social care are deep. Securing greater investment and reform by central government is likely to take time, and requires public support. But change that takes time and is hard won can be the most effective and lasting change. Our hope is that the case for reforming social care, which has been made for several decades, is now reaching a point where lasting change and real investment will be delivered in the near future, and the health and quality of life of older people will improve as a result. Until then we will keep working to ensure that all older people in the UK receive the care they need at the right time and in the right place.
BGS Policy Manager