- Although the proportion of individuals with a disability is similar across all four countries, the proportion of the population receiving disability living allowance, personal independence payments and attendance allowance is variable. However, across all types of benefit, the proportion of recipients is consistently lower in England than in the other countries. This could be explained by the others’ relative higher rates of poverty, and/or individuals in those countries having comparatively more severe or complex disabilities.
- In all countries, there is a lack of clarity around which people with social care needs are eligible for funded health services. In England, Wales and Northern Ireland, the issues surrounding continuing health care (or its equivalent) are well rehearsed, particularly in relation to those with dementia who typically do not qualify for funding for care. Scotland is the only country to have reformed the system to offer more certainty about the delineation between the two services, although what impact this has had on access is unclear.
The extent to which benefits are devolved is limited. The Department for Work and Pensions manages benefits, set at the same level, for England, Scotland and Wales (although this is set to change in Scotland over the course of the next few years). In the case of Northern Ireland, benefits are administratively devolved to the Department for Communities but the type and value are identical to benefits in the other countries under current arrangements.
Yet while the proportion of individuals with a disability is broadly the same in relation to the overall adult population of each of the four countries, spending on welfare benefits differs greatly. These differences in spending could be due to a number of reasons. A higher number of applicants in the other countries could reflect different expectations of the state, a higher proportion of individuals with a (more complex) disability in the other countries, and/or a greater proportion for whom the payout is of greater financial significance.
Benefits are centrally organised and administered by the Department for Work and Pensions. For working-age adults, the disability living allowance is progressively being replaced by the personal independence payment.
As in England (and Scotland at time of writing), benefits are centrally organised and administered by the Department for Work and Pensions. Spending on benefits in Wales is comparatively higher than in England. Literature suggests there is a greater need in Wales for the state to provide support – the Wales Fiscal analysis reports the number of over 65s claiming disability living allowance and personal independence payments is almost twice as high as in England. This could potentially be explained by a comparatively higher level of disability due to higher incidence of chronic disease and greater health inequalities. Furthermore, the higher spending on benefits could be explained by a proportionally greater number of individuals for whom receiving a benefit payment is financially significant. Wales has the highest level of poverty in the UK, especially among working-age adults.
However, there is currently some appetite in Wales to follow Northern Ireland and Scotland in the devolution of benefits, following reports this would increase the Welsh welfare budget.
Although Scotland currently operates its welfare benefits under the centrally administered Department for Work and Pensions, these are to be progressively devolved to, and managed by, Social Security Scotland – starting in April this year.
Social Security Scotland currently administers an additional benefit to Scottish carers, namely the carers’ allowance supplement. This additional benefit takes the form of two payments a year that align carer benefits with the job seekers’ allowance, which will be incorporated into the carers’ allowance when Social Security Scotland takes over the benefit’s administration.
Other changes that are planned for the newly acquired devolution is to replace the personal independence payment with disability assistance, starting in 2021.
In Northern Ireland, benefits are organised and administered by the Department for Communities, although in practice the rates of pay are the same as in England and Wales.
Although the country is also transitioning from the disability living allowance to personal independence payments, the devolved department has put in place additional support for those affected by the transition. For example, if the loss is greater than £10 per week, the individual is entitled to a supplementary pay of up to 75% of the amount received under the disability living allowance – for a year. Individuals suffering from injuries relating to the Northern Ireland Conflict are also entitled to a supplementary payment from the Department for Communities.
Spending on benefits is comparatively high against the other countries of the UK. Conversations with stakeholders reflected that this is partly due to an increased expectation of the state to support individuals in the aftermath of the Conflict.
Support for health needs
Under the NHS Continuing Health care (CHC) scheme, individuals whose social care need is, according to an assessment process, deemed to be the consequence of a primary health need do not pay for their social care. They are instead fully funded by the NHS, regardless of the setting in which they receive their care or the type of package they need (this includes accommodation costs for residential and nursing care). The assessment uses the national assessment tool and is undertaken by the local clinical commissioning group. Individuals with a social care need who are deemed responsible for paying for their own care, and who require the medical support provided by a nurse in a registered care or nursing home, are entitled to a payment of £165.56 per week from the NHS, directly to the nursing home.
There have been major concerns around CHC delivery in England, in particular around the low number of people deemed eligible after assessment, waiting times and where the responsibility lies between the health and social care systems. It is furthermore felt to be a source of inequality particularly for dementia sufferers, whose needs are often perceived to fall under social rather than health care. These were recognised by the government in 2018, but it is clear those problems continue to persist and have been the object of increasing public and media attention. The House of Commons Library has recently published a briefing on CHC in England and UK-wide, suggesting this continues to be a political priority for debate.
NHS Digital collects data from clinical commissioning groups, and records on average 56,000 service users eligible for CHC at any one point in 2018/19.
As in England, the Welsh NHS covers the full social care costs of individuals who require social care arising from a health need after an assessment, regardless of the setting in which they receive their care or the type of package they need (this includes accommodation costs for residential and nursing care). Care is then organised through local health boards. Most recent reports from the Welsh government indicate that, on average, approximately 5,000 Welsh people receive NHS-funded continuing health care at any one point. Individuals with a social care need who are deemed responsible for paying for their own care, and who require the medical support provided by a nurse in a registered care or nursing home, are entitled to a payment of £179.97 per week from the Welsh NHS directly to the nursing home.
As in England, there have been similar concerns raised in Wales about the consistency and fairness of the CHC assessment process. Dementia sufferers are also deemed to be treated unfairly. The CHC process in Wales was recently under consultation and a revised framework is expected shortly.
After an independent review of NHS Continuing Health care in 2014, the scheme was replaced by Hospital Based Complex Clinical Care in 2015 – under which the NHS would fully meet the costs of care for service users with a health need if they needed to be delivered within a hospital setting. Individuals whose care needs can be “properly met” in a setting other than a hospital must meet their own accommodation and board costs.
Their other social care needs are met in the same way as other service users who are not deemed to have a primary health need (see ‘Offer and eligibility’), including the delivery of free personal care if the individual has an eligible need. In addition, all service users requiring nursing care within a care home setting receive this for ‘free’, delivered by the local GP. This takes the form of a weekly payment of £80 from the local authority directly to the care home.
According to the government inpatient status in 2018, around 940 individuals were receiving Hospital Based Complex Clinical Care. These numbers are not directly comparable to those in England, as they represent only those individuals whose care costs were fully met by the NHS in a hospital setting.
Continuing Health care in Northern Ireland is offered to individuals for whom the outcome of an assessment is a primary health need (as opposed to a primary social care need – for more details see ‘Offer and eligibility’). In such cases, the health and social care trust must meet the full costs of the individual’s care package, regardless of the setting (this includes accommodation costs). Individuals with a primary social care need who are deemed responsible for paying for their own care, and who require the medical support provided by a nursing home, are entitled to a payment of £100 per week from the health and social care trust directly to the nursing home. As for all service users, individuals whose needs can be met in a domiciliary setting can do so for free.
A 2014 report from Age Northern Ireland denounced the denial of continuing health care to many citizens in Northern Ireland. The report finds only 43 individuals who were eligible for continuing health care between April 2011 and September 2016, although this excludes service users receiving care within a domiciliary setting (as this is provided free to all users regardless of a primary health or social care need). As such, the Northern Ireland Executive started a consultation on a review of continuing health care in 2017. The outcome of this consultation process isn’t yet clear.
Oung C, Curry N and Schlepper L (2020) 'Other types of support: how do the countries compare?', in Adult social care in the four countries of the UK. Explainer series, Nuffield Trust.