In March, Baroness Casey called for a ‘moment of reckoning’ for social care, noting it has lacked the design moment that the NHS had in 1948. Instead, it has evolved in a piecemeal way, layered with assumption, opacity and inconsistency. The boundary between the role of the state and the responsibility of individuals and families in supporting people has remained blurry. As Andy Burnham takes office and the Casey Commission kicks off a ‘national conversation’ with the public about the future of social care and its role in our lives, this is a once-in-a-generation opportunity to renegotiate the social contract for social care.
Of course, this wouldn’t be the first attempt at social care reform, nor the first public debate. Burnham himself presided over the Big Care Debate in 2009, when he launched the idea of a ‘national care service’ while Secretary of State for Health (with remit for social care). While that exercise successfully engaged with tens of thousands of people, the 2010 election campaign saw debate descend into political mud-slinging with plans branded a ‘death tax’. Seven years later, we witnessed Theresa May’s proposals being branded a ‘dementia tax’. In the intervening periods, before and since, several proposals for reform have come and gone.
So what needs to be different this time to make sure the next set of proposals leads to change? Principally, the starting point needs to be different. Public and political debates around social care have too often started and ended with two questions: how much will it cost and who should pay? This framing has quickly reduced debate to the narrow, divisive and politically toxic issues of inheritance and selling homes to pay for care.
Questions about costs cannot be avoided but, as the starting point for debate, they distract from some more fundamental issues that should underpin reform decisions. Namely: what is the role of the state in providing support when we struggle to maintain our independence, either because of disability, ill health or old age? What are our expectations of the state versus our own or our family’s responsibility to support us? And what is the fairest way to ensure our social care system is able to support people who are in need of care and support? None of these questions have simple answers and there are some stark policy choices ahead.
Looking further afield
To inform, and provide new ideas for, that conversation, we have been working with the Joseph Rowntree Foundation to explore what different approaches to the balance of individual and state responsibility could look like. As part of that work, we at the Nuffield Trust have been exploring where other countries or regions draw the line between state and individual responsibility. We have chosen 11 countries or regions that demonstrate varying approaches, and different mechanisms, to deciding on the generosity of the state offer.
No other country or region’s approach provides an ‘oven-ready’ solution, as design needs to be rooted in our own values and concepts of fairness, but the design choices and trade-offs that others have made raise a series of useful questions for further exploration.
Six key observations from our research prompt debate:
1. England is one of few systems where access to any public funding for care is restricted by how much money people have
All of the countries and regions we have studied require people to go through an assessment of their needs to access public funding. But England stands out from the pack, in that people must also pass a financial test to be considered for any state-funded support at all. Only Wales operates a similar system across all settings, while New Zealand and Northern Ireland take this approach only for residential care.
Anyone in England with financial means above £23,250 has no access to public funding. Even below that, needs must be significant to warrant eligibility for funding. As such, England’s system concentrates resources on those with the lowest financial means and highest care needs. In contrast, the other systems in our sample provide something to everyone with eligible needs, albeit not entirely free at the point of use.
What makes England’s system particularly narrow is that this condition of entry has not evolved in line with inflation. The thresholds have been frozen since 2011. The pool of people who are being found eligible for public funding is becoming increasingly smaller. The threshold creates a sudden cliff edge, felt particularly by those with low-to-moderate means who just tip over the threshold, and who are left with the choice of self-funding all of their care, living with unmet needs, or heavily relying on unpaid carers.
For the purposes of comparison, New Zealand operates a similar system for residential care, but it is more generous, with anyone holding the equivalent of approximately £128,000 in assets and savings in the current year (around NZ$300,800) able to access some public funding.
2. No country/region has a system that is fully free at the point of delivery, but some come close
Although most systems offer something to everyone, this doesn’t necessarily mean that all care is free. However, Denmark comes close. By far the country/region with the most generous offer in our sample, anyone in Denmark aged over 65 1 and assessed as having an eligible need for care can access all of the care that meets their needs for free, regardless of their financial circumstances. This does, however, exclude the cost of accommodation in residential care, which the person is expected to pay in full, albeit with access to means-tested housing benefit where required.
While not coming close to the generosity of the Danish system, some others provide elements of care for free. In New Zealand, homecare is free to all. This is also the case in Northern Ireland, where health and social care trusts have the powers to charge for domiciliary care services but do not usually do so. Others provide a more constrained offer with free access to a specific package of care to anyone with an eligible need, such as free personal care in Scotland, or ‘clinical’ care (e.g. nursing and physio) in Australia. Although the generosity of each of these examples varies, they all provide a level of entitlement to at least some state support.
But they have not been without controversy. Scotland’s free personal care offer has been criticised for being too narrow and inflexible for some. Australia introduced a new system in late 2025 that included free clinical care but charged for personal care in the home. After a backlash, the government has recently decided that personal care in the home should now be free.
Defining what is in or out of a defined package is a difficult tightrope to walk. It also relies on the public having a good understanding of the terminology – what’s social care versus personal care is likely not a distinction that many people understand. Some systems (such as Germany and Japan) favour defined monetary amounts instead of a defined package – this approach is explored more below.
3. Countries/regions have different approaches to what is a fair, equal and equitable contribution
Although most of the systems offer something to everybody, all (except Denmark) expect individuals with an eligible need to make contributions to the cost of their care. The design of these co-payment systems varies based on different choices, trade-offs and notions of what’s fair and acceptable in each society.
In Germany, for instance, the system is designed with equality in mind, with everyone receiving the same level of state funding in the form of a monthly allowance according to their level of need, regardless of financial circumstances. Beyond the monthly allowance, though, individuals are liable for all their remaining care costs.
Others, such as Japan and Australia, provide everyone with the same basic offer or allowance, but then split the remaining costs between the state and individual according to the person’s financial circumstances. In Japan, this involves three broad contribution levels of 10%, 20% or 30%, whereas in Australia a complex series of tapered calculations is deployed to determine each individual’s ‘fair’ contribution. A third way is taken by France and Catalonia, where everyone is guaranteed something but that ‘something’ is proportionate to financial means and level of need. This means that in France, for example, even the most wealthy receive some state funding, but it can be as low as 10% of care costs.
New Zealand and Canada favour a different approach still, in which people exceeding a defined financial threshold are required to pay for all their care up to a specified percentage of their income. The state then steps in to cover the difference where that income does not meet the total cost of care. As such, everyone contributes towards their care while protecting an equal proportion of their means.
4. Means tests can be designed to feel fair and avoid cliff edges
People having to sell their home to pay for their care is a persistent source of discontent in the English media. On taking office, then Prime Minister Boris Johnson promised that no one would have to do so under his plans. These plans did not fully materialise but it is a question that will no doubt reappear in due course. The centrality of property and property wealth in English culture means it is also a question that cannot be ducked. Looking beyond our borders, there is an array of approaches to means-testing, with some differences in what’s assessed and what’s excluded, which often reflect societal attitudes to fairness.
Japan’s test, for instance, includes only income (including pensions). The exclusion of all assets perhaps reflects a different cultural and practical relationship with property, shaped by the country’s volatile physical geography, although societal shifts are leading to discussion about inclusion of assets from 2027. An interesting feature of Japan’s test, though, is that the income is that of the entire household, not just the individual or their spouse. British Columbia in Canada also only considers income. In their system, people are required to pay a sizeable portion of their income towards care costs but they are not forced to liquidate assets.
In contrast, to access any public funding in New Zealand, only your assets are considered (with income then assessed to calculate your contributions). In this system, there is a single asset threshold, above which people are not eligible for public funding. This is similar to England’s model, except the New Zealand threshold is set more generously at around NZ$300,800, which is roughly £128,000 compared to England’s £23,250.
Most others, including Australia, France and the other UK countries, consider both income and assets but deploy different formulae and approaches, with Australia favouring a complex series of tapers and exemptions. In line with England’s approach, almost all exclude someone’s primary residence when being assessed for homecare and in certain circumstances for residential care.
5. Some, but not all systems, seek to protect individuals from unlimited costs
Almost all the systems we have studied, including England’s, protect individuals through a safety net designed to leave individuals with a minimum income to live on, or for personal expenses in residential care, after care costs. In some systems, wider social welfare provides a safety net for those struggling to meet their costs. But how much they are left with can be more or less generous. In Wales, for instance, individuals living in a care home can keep £46.35 per week, which is almost £15 a week more than is the case in England.
Some systems also limit how much an individual will have to pay for their care through the use of caps – a policy that has been repeatedly proposed but not implemented in England. Countries and regions have made different design choices, offering varying levels of protection and certainty over individual costs.
Australia operates a version similar in design to that proposed in England, in that an individual’s contribution over a lifetime is fixed. The state steps in after a person has either paid around AUD$135,000 (roughly £70,000) or they have paid for any amount of care for over four years. But the cap only applies to a specific element of care (non-personal care costs), leaving individuals still paying for a range of fees categorised as daily living costs, hotelling and accommodation for as long as they require care.
Elsewhere, caps are set on a weekly or monthly basis, which means that the person will continue to pay for as long as they access care. In Wales, for instance, no one pays more than £100 a week for homecare, but will continue to be responsible for the costs of their care up to that amount until they fall below the threshold for state-funded care. New Zealand operates a similar model in residential care, with weekly caps on total costs (including accommodation), but these are set regionally.
Japan’s approach is unique in that it operates a series of caps that vary by individual financial circumstances, ranging from a maximum of £70 a month for the poorest individuals to £650 for those who are better off. Again, with no absolute lifetime cap, everyone continues to pay for as long as they need care.
While the weekly or monthly approach provides less certainty over total lifetime costs, there are a number of systems with no cap on costs besides the UK countries. France is one example, Catalonia another. Germany debated the issue for some time but rejected the concept of a cap in favour of a subsidy for people in residential care, which means the longer you stay in a care home, the smaller the percentage of costs you cover down to 30%. The state pays the rest, but the individual continues to contribute their portion for as long as they are resident.
6. Most systems treat accommodation costs separately
In UK residential care, the costs of care are bundled together with the costs of accommodation, food and utilities. As such, the individual (or local authority) is billed for a single amount per month with no breakdown of costs. In our sample of systems beyond the UK, only New Zealand, Catalonia and British Columbia take a similar approach.
Most other systems treat accommodation costs separately – with caps, co-payments and subsidies applied only to care costs – leaving individuals to fund their accommodation in full. Some state subsidies are available where people cannot meet accommodation costs, for example in France where the state assists in cases where income falls short. Even in Denmark, where the care offer is the most generous, individuals in residential care are expected to pay their accommodation and ‘hotel’ fees in full (although access to means-tested housing benefit helps anyone struggling to cover those costs). Australia supports people’s accommodation costs but only under a certain financial threshold.
Separating accommodation from care costs offers a greater level of transparency as to what people are paying for, allows them to pay more or less for the level of luxury desired, and focuses the social contract on care only. It does, however, mean that people in residential care can be at risk of substantial bills for living costs.
Some systems have brought in strict rules that govern accommodation and ‘hotel’ fee setting, including setting maximum rates or fixing in legislation the percentage of a fee that can be retained for management costs by the provider. In Germany, the amount that can be charged to an individual for non-care fees is part of the annual provider fee negotiations that take place at a state level. Similarly, Denmark has a national cap on what a care home can charge for food.
Australia’s new system has a range of rules and regulations that govern these aspects. For instance, the hotelling element is part subsidised by the state with a daily cap on the individual’s contribution. Providers are also held to strict rules and are required to provide the individual with a detailed breakdown of costs. Furthermore, although accommodation fees are negotiated between individual and care home, a maximum for what a provider can charge for accommodation is set nationally and subsidies are accessible for those passing a financial means test.
However, accommodation costs can be significant – on moving into a home, people have the choice to pay via a refundable lump sum or via a daily fee (or a combination). Care homes can charge up to around AUD$789,700 (roughly £410,000) for that lump sum. This is refunded once the place is no longer needed, minus the accumulated daily living fee and a fixed 10% management fee.
Drawing the line
The features of other systems we have highlighted simply scratch the surface of the complexity that lies beneath each. It’s complex stuff but, beyond the intricate technical detail, at the heart of this is a fundamental question about state and individual responsibility. What the international examples demonstrate is that there is no single approach, no ‘right’ way, but instead a series of design choices.
However, the English system has evolved in an ad hoc manner with design features embedded in isolation of broader considerations of fairness or societal expectations. At present, the system is beset with a considerable degree of uncertainty and variation. It concentrates resource on a relatively narrow (and shrinking) cohort of the population, where even people with only very moderate wealth fall outside the criteria for any support and can face unlimited costs.
The Casey Commission’s conversation provides an opportunity to question whether that design is what we want and need as a society, and to explicitly consider if we are prepared to pay more for better or broader coverage. It needs to carefully test out what the public feel is a fair balance of responsibility between state and individual, and to understand what sort of social care system we want for ourselves now and in future. But, while the debate with the public is an important exercise for unpicking deep-seated social values, inevitably the government will face some stark policy choices and will need to make some tough calls.
The central tension will be between generosity and affordability. It’s no secret that this conversation is happening against a backdrop of unprecedented global and domestic financial pressure, with other government departments competing for resource. Social care does not operate in a vacuum, and developments and policy choices being made in adjacent sectors (the NHS, housing and benefits to name a few) will also need to be considered.
It is notable that several of the systems we have looked at are beginning programmes of reform that are set to tighten the state offer, demonstrating that even the most established systems are having to respond to increasingly challenging financial climates.
Once a funding envelope for social care is set, the government will be faced with a series of trade-offs and choices that will determine ‘winners’ and ‘losers’. The current system concentrates resources on the poorest and neediest. The government could opt to retain those guiding principles and seek to provide more and better care for those already in the public system, paying staff more and stabilising providers.
Or, it could seek to widen the pool of people who can access public support, from a modest extension to the current pool (such as by raising the asset thresholds or implementing a cap on costs) to a wholesale shift towards a system where everyone gets at least something, possibly with means-tested co-payments alongside.
The original Burnham vision for a National Care Service in 2009 – and reiterated in his 2015 leadership bid – was one that was (eventually) free at the point of use, in line with NHS principles. Whether that still feels feasible in the current context will be something the new Prime Minister will need to wrestle with. Clearly, the more generous the system, the bigger the price tag.
These choices need to be weighed against considerations about how best to build public support. Shifting funding from other public services or increasing taxes (or other revenue-raising approaches) to fund the new system will require public support. Being able to guarantee access to at least some public funding to all might go some way to securing this, but that will come at a cost.
Ensuring that people understand what that offer is, and how it is an improvement on the current situation, will be vital. With around a third of the public mistakenly of the belief that social care is free as part of the NHS, the Casey conversation is important for testing out values and boundaries but also in raising awareness of how things work now.
Once a firm set of principles around the ambition of the system, priority groups and the ideal balance of responsibility is arrived at, the government has a rich source of inspiration and learning to draw from in the experiences of other systems. Various approaches to caps, co-payments, means tests and minimum guarantees can be deployed to deliver a system that fits the ambition.
The Casey Commission conversation, timed as it is, could serve as a useful exercise for Burnham to demonstrate his commitment to social care reform and to really engage with the fundamental questions that, to date, have been brushed over or not fully addressed. There is an opportunity, with strong political leadership, to make explicit previously unspoken assumptions and expectations. There will be tough choices. There will be winners and losers. But by focusing on the principles and trade-offs, Andy Burnham could be the Prime Minister who goes down in history for putting right three decades of policy failure.
Please note that specific figures (such as monthly benefits, caps, and means test thresholds) are subject to review and indexing at different points in time and with varying regularity – those included for different countries are correct at the time of publication. Any equivalent values shown in pounds sterling for other currencies are based on the exchange rate at the time of conversion, so are subject to change.
This accompanying paper provides a comparative analysis of cost-sharing approaches in 11 other countries and regions.
We are grateful to the Joseph Rowntree Foundation for providing funding for this research.