Offer and eligibility: Who can access state-funded adult care and what are people entitled to?

Key points

• All of the countries operate a means and needs test to determine access to social care support from the local authority or health and social care trust. England is the least generous country in its offer, as Wales, Scotland and Northern Ireland offer additional support outside of the means test.
• The number of state-funded individuals varies considerably across the countries, with the greatest differences arising for these over 65. The high number of over-65s accessing state-funded care in Scotland is likely a consequence of their free personal care policy.
• Across each country, there is a drive to promote the use of personal budgets (or self-directed support) to push greater personalisation in social care.
• Determining which services are included in the offer (for example, in free personal care in Scotland) has proven a challenge in all of the other countries.

* N.B. upper threshold in Wales applies only in residential care.

In practice, personal budgets and self-directed support are the same delivery mechanism. Stakeholders suggested the use of different terminologies reflected different emphases – and an aversion to the term “personal budgets” in the other countries.

England

Access to state-funded care is determined both by a means test and a needs test. These are both carried out by a person’s local authority, and were revised under the Care Act (2014), which is enshrined in ‘person-focused’ principles.

Any individual deemed to have some need for care is entitled to an assessment by their local authority, regardless of whether they are financially eligible.[3] National eligibility criteria for need were set out under the Care and Support (Eligibility Criteria) Regulations 2014 around a person’s ability to achieve their desired outcomes in relation to their wellbeing.[4] There are three conditions that must all be met for an adult to be considered to have an eligible need:

1. The considered individual has a need arising from a physical or mental impairment or illness
2. The considered individual is unable to achieve two or more outcomes as listed in the Care Act
3. Being unable to achieve these outcomes is likely to have an impact on the individual’s wellbeing (as defined in the Care Act).

For those meeting the needs assessment threshold, the second part of the eligibility process involves a means test.

• For anyone of any age with means (which includes income, assets and savings) in excess of £23,250, there is no state support available for care, and costs fall entirely on the individual. These represent the majority of social care users in England.
• Anyone with assets between £14,250 and £23,250 may be able to access some funding, depending on level of need.
• Anyone with assets below £14,250 are able to access full funding, depending on level of need, but may nonetheless have to contribute from their income where a care package doesn’t fully meet a person’s wants or needs (e.g. top ups for care homes).
• A person with more means than the upper threshold of £23,250 can ask their local authority to arrange support for them, but the local authority has no requirement to do so.

Any person meeting both the needs and means tests must be provided with a person-led care and support plan by the local authority. This includes a personal budget – an estimate of the total care costs that the local authority will fund, which can be delivered as follows[5]:

1. A direct payment to the service user
2. Service paid for and provided by the local authority
3. Funding from the local authority to the provider of choice
4. A mix of all these options.

If a person does not meet the needs or financial threshold, local authorities are required to provide information and advice to the individual. England has the highest proportion of self-funders of the four countries, especially in residential and nursing care. Estimates from various sources suggest self-funders represent approximately 46% of all residential and nursing care users, and in the domiciliary care sector they represent around 30%[6] (see ‘How much social care does each country fund?’).

The inequalities in access between local authority-funded individuals and self-funders will be discussed further in an upcoming explainer in the series on the provider market.

Wales

Access to state-organised and funded care is determined both by a means test and a needs test. These are both carried out by a person’s local authority and were revised under the Social Services and Wellbeing (Wales) Act 2014, which is enshrined in co-production principles, among others. Any individual deemed to have some need for care is entitled to an assessment by their local authority, regardless of whether they are financially eligible.[7]

National eligibility criteria were set out under the Care and Support (Eligibility) (Wales) Regulations 2015, but it is recognised in statutory guidance that the “pattern of service delivery will vary from authority to authority”.[8] As the Social Services and Wellbeing Act is a “people act”, eligibility conditions apply to adults, children and their carers. There are four conditions to be met, which are:

1. The person’s needs arise from circumstances in the eligibility regulations, for example around physical or mental ill health
2. The needs of the person relate to one or more of those listed in the Act
3. The person is unable to meet that need alone (regardless of whether they are receiving help from a carer or the community)
4. The person is unlikely to achieve one or more of their personal outcomes without support from the local authority.

If a person does not meet the needs threshold, local authorities are required to provide information and advice to the individual.

Any person meeting the needs threshold must be provided with a care and support plan developed in partnership with the individual, which reports the outcomes, actions and needs identified and the resources that will be given to support these. Care and support plans also include details of the needs (some or all) to be met with direct payments, and how frequently these will be paid out. It is compulsory for local authorities to offer direct payments to older people who meet the necessary criteria.[9]

For those meeting the needs threshold, the second part of the eligibility process involves a means test. The process is different depending on the setting in which care is delivered.[10] In residential care, the process is as follows:

• For anyone of any age with means (which includes income, assets and savings, including the value of their home) in excess of £50,000, there is no state support and nearly all costs of care fall entirely on the individual.[11] A person with more means than the threshold of £50,000 can require the local authority to arrange support for them, and the local authority has a duty to do so.
• Anyone with assets below £50,000 will be able to access full funding support from the state, the level of which is set out in the care and support plan.[12] The raised threshold was announced in April 2019[13], meaning more people are now entitled to state support. Local authorities have discretion to disregard some sources of income as long as this is applied consistently within their jurisdiction. These individuals may nonetheless have to contribute from their income.
• There is no cap on costs in residential care.

Non-residential care costs (i.e. costs within an individual’s home and the community) are capped at a national maximum £90 per week for all individuals, regardless of their means and how much care and support services they receive. Local authorities have discretion to provide these services for free, but none do so currently.[14] The level of the cap was raised by £10 per week in April 2019.[15] Local authorities can also choose to operate a lower cap, meaning individuals receiving non-residential services would have to pay less for their care.

Estimates of the proportions of self-funders in Wales suggest these are much lower than in England, both in residential/nursing and domiciliary care (especially in the domiciliary care sector). Approximately 32% of people receiving residential or nursing care in Wales self-fund, while in domiciliary care this proportion is around 21%[16] (see ‘How much social care does each country fund?’).

More details about the inequalities in access to services between local authority-funded individuals and self-funders will be discussed further in an upcoming explainer in the series on the provider market.

Scotland

Local authorities are responsible for the assessment of a person’s eligibility for social care under the National Eligibility Criteria – eligibility was previously regional. These were developed between the Scottish government and the Convention of Scottish Local Authorities in 2009.[17] The eligibility assessment follows a two-stage process: assessing a person’s needs and personal outcomes[18], and assessing whether achieving these outcomes require services to be put in place. The National Eligibility Framework sets out four levels of need: critical, substantial, moderate or low risk. Local authorities have discretion to set the level of need at which services are delivered.[19]

Any person meeting the needs threshold must be provided with a self-directed support plan[20] , which is being progressively rolled out until 2021 and provides an estimate of the total care costs the local authority will fund.[21] It can be delivered as follows[22]:

1. A direct payment to the service user
2. Service paid for and provided by the local authority
3. Funding from the local authority to the provider of choice
4. A mix of all these options.

If a person’s self-directed support plan requires personal care, this is provided for free to all adults by the local authority, and must be provided to individuals with a critical or substantial level of need weeks within six months of the assessment outcome.[23] Personal care includes personal hygiene, continence management, food and diet management, assistance with mobility, counselling and support, simple treatments, and personal assistance.[24]

Individuals requiring personal care to be delivered within a care home setting receive a weekly payment of £177, directly from the local authority to the care home to cover the costs of this care.[25] Until April 2019, personal care was only free to the over-65s – this has now been extended to all adults after an extensive campaign.[26]

For social care needs identified in the self-directed support plan that fall outside of personal and nursing care, a means test is applied[27]:

• For anyone of any age with means (which includes income, assets and savings) in excess of £28,000, there is no state support for social care activities that fall outside of personal and nursing care.
• Anyone with assets between £17,500 and £28,000 may be able to access some funding, depending on level of need.
• Anyone with assets below £17,500 are able to access full funding, depending on level of need, and will nonetheless have to contribute from their income.

What social care activities could fall under free personal care? 03/10/2019

Chart

Note:  

This diagram is for illustrative purposes only, based on Scottish legislation of activities that can be included in free personal care. It does not attempt to provide an exhaustive list of all activities and actors involved in the social care sector.

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Estimates of the proportions of self-funders in Scotland suggest these are considerably lower than in England, both in residential/nursing and domiciliary care. Around 36% of individuals in a residential or nursing home self-fund, while approximately 25% of domiciliary care users pay for their care themselves[28] (see ‘How much care does each country fund?’).

More details about how self-funders and local authority-funded individuals experience different access to services will be discussed further in an upcoming explainer in the series on the provider market.

Northern Ireland

Access to state-funded care is determined both by a means test and a needs test. Any person in need of care and support is entitled to a health and social care needs assessment (under the Northern Ireland Single Assessment Tool) by their health and social care trust[29] regardless of their financial eligibility. The assessment covers both health and social care needs due to the integrated nature of the system.[30] This is undertaken by all practitioners involved in the care of an individual.[31]

For individuals who are assessed as having a social care predominant need (as opposed to a health predominant need – see ‘Other types of support’), the second part of the eligibility process involves a means test[32]:

• For anyone of any age with means (includes income, assets and savings) in excess of £23,250, there is no state support available for care and costs fall entirely on the individual.
• Anyone with assets (as above) between £14,250 and £23,250 may be able to access some funding, depending on level of need.
• Anyone with assets (as above) below £14,250, are able to access full funding, depending on level of need, and will nonetheless have to contribute from their income.

Any person meeting the needs test and the means test must be provided with a self-directed support plan, which is being rolled out across trusts in a phased approach.[33] This includes a personal budget that estimates the total cost of social care activities to meet ‘individual outcomes’, and can be delivered as follows:

1. A direct payment to the service user[34] 
2. A managed budget held by the trust but controlled by the service user
3. Support organised by the trust
4. A mix of all these options.

All individuals who qualify for social care support in the home are entitled to free domiciliary care[35] [36], which covers most personal care and domestic services[37] except usually meals on wheels[38]. It is widely understood that health and social care trusts have the power to charge for domiciliary care but normally choose not to do so.[39] Stakeholders in Northern Ireland suggest this is unlikely to change in the near future. Although the service is provided for free, most recent data on domiciliary care provision[40] highlighted that over 30% of domiciliary care visits lasted 15 minutes or less, and over 43% of service users received a visit lasting 15 minutes or less.

Estimates of self-funders are, by a large margin, the lowest of the four countries. Only 11% of service users in a residential or nursing care setting pay for their care themselves, while it is estimated that only 7% of domiciliary care users are self-funders[41] (see ‘How much social care does each country fund?’).

More details about the inequalities of access to services between self-funders and local authority-funded individuals will be discussed further in an upcoming explainer in the series on the provider market.