Social care across the four countries of the UK: what can we learn?

As we start a series of explainers describing the social care system in each country of the UK, lead author Camille Oung looks at what social care policy-makers in England can learn from Scotland, Wales and Northern Ireland. Reform must come with funding and clarity – and it must secure public support.

Blog post

Published: 18/03/2020

On becoming Prime Minister, Boris Johnson promised to “fix social care once and for all” in England. Yet eight months on and, beyond a £1.5 billion short-term sticking plaster for 2020/21 and a commitment to finding a “cross-party consensus”, talks for which are expected in May, a long-term plan for reform is still awaited.

As that wait continues, we’ve been looking at England’s nearest neighbours, with over 20 years of devolution in the UK leading to important differences in the social care systems in Scotland, Wales and Northern Ireland.

We have collated those in a new series on social care in all four UK countries. Today we start by looking at key themes around funding, eligibility and ‘offer’, while considering the direction of current reform.

Similar but different

Although the systems do diverge, all four countries share two important similarities:

1) In each country it is felt that the current system is inadequate, and reform is either currently underway or on the cards.

2) Currently, a means test determines whether someone can access state funding for at least some social care services.

The level of that means test, and the surrounding offer, is on the whole more generous in Scotland, Wales and Northern Ireland than in England. Scotland has free personal care, Wales operates a weekly cap on non-residential care costs, and Northern Ireland provides domiciliary care services free of charge.

What is clear, however, is that every system has its challenges and that no country has quite cracked it. But the experiences of those in Scotland, Wales and Northern Ireland – both positive and less so – do point to some important lessons for social care policy-makers in England.

Lesson 1: Reform must be backed up by funding

While the extra cash pledged by the government in England has generally been welcomed, it is yet another one-off injection in a succession of piecemeal funding solutions that seek only to prop up a struggling system in the short term. There are concerns that long-term sustainability is likely to be limited if reform is not accompanied by a significant overhaul in the way adult social care is funded, injecting new money into the system.

Experience in the other UK countries – which, like England, have had no substantial change to social care funding over the last 20 years – demonstrates that. The immediate consequences of introducing free personal care in Scotland have been covered in more detail elsewhere, but raise some important learning for England.

Many Scottish local authorities reported underfunding, leading to ‘rationing by queueing’, with formal and informal waiting lists for assessment and referral to personal care services. Charges for other services such as food preparation, which had previously been free in certain councils, were introduced in an attempt to mitigate the shifting costs to personal care delivery.

Similarly, in Northern Ireland, advice states that no home care visit should last less than 30 minutes, yet insufficient resources has meant that, in reality, the majority of domiciliary care visits are limited to half that time. Key reform proposals, such as Power to People, have subsequently recommended a review of current funding arrangements. Wales is also actively considering a range of different sustainable funding options ahead of a consultation on the matter this summer.

Lesson 2: Secure public buy-in

A major issue hindering reform in England is poor public understanding of the current system, with many expecting it to be free. As radical reform will inevitably require higher spending, it is no surprise that the Prime Minister steered clear of being anything more than vague on the issue in last year’s general election. The other UK countries suffer from similarly low levels of public understanding, but have differed in their response to addressing that issue.

It’s not evident there has been the same effort to bring the public in England into discussions around social care as has been the case in Scotland and Wales. The principle of co-production was featured in England’s 2014 Care Act, but it’s debatable whether it has actively been embedded in public service reform. Yet in Scotland, mechanisms such as the people-led policy panel have been designed to involve citizens directly in the construction of a shared vision for social care.

Such engagement activities, whether to understand public perceptions or actually build them into the design of policy, could offer a way to create public buy-in and consensus around the values we want for social care in England too – without which we risk a repeat of previous electoral cycles and ongoing delays to reform.

There is now growing public and political concern about social care and a real opportunity to create public consensus around the possibilities for reform. Putting effort into raising awareness among the public, and engaging them in meaningful debate about the service they would like to see created, will be crucial in establishing a sustainable and effective system.

Lesson 3: Create a clear offer

England’s care system is frequently described as confusing, opaque and complex. Regional variation in eligibility and inconsistent application of the means test fuels a sense of unfairness, and a lack of clarity over the services a person might have access to is a source of deep anxiety. Navigating the complex financial assessment can unsurprisingly be daunting at a time when individuals face huge vulnerability.  The Scottish, Welsh and Northern Irish systems also suffer from similar complexities, and their experiences highlight the importance of establishing an offer that is consistent and clear across the country.

Scotland, Wales and Northern Ireland provide those who are eligible for social care with some services that are not means-tested. While that more generous offer might be welcomed in England, defining what that means in practice has been difficult. For instance, free personal care is becoming increasingly appealing to policy-makers in England as a potential solution to the many problems that beset the English system – but the journey in Scotland to determining who is able to receive free personal care, and what that actually includes, has not been smooth.

When the policy of free personal care was launched in Scotland in 2002, there was no national definition and what local authorities offered free of charge varied considerably. Legislation in 2005/06 sought to create consistency, yet what is often not understood in England is that the offer was only extended to adults under 65 in Scotland in 2019. It also comes as a surprise to some that anything outside of free personal care activities (such as help with shopping and cleaning, or general supervision for dementia sufferers) is subject to the means test, just as it would be in England.

Similar questions around clarity arise in Wales and Northern Ireland, where both systems usually have exceptions to the services they provide for free – further complicated by regional variation in access and offer. Such uncertainty leaves many anxious about their futures or, in many cases, unprepared for substantial care bills.

Whichever route England chooses, it would be wise to seek clarity from the outset to avoid subsequent years of uncertainty and further legislation. Public support for a system will be nurtured if individuals can be confident about which services they can access free of charge, wherever they are in the country. It will also help individuals to better plan financially for their future.

Time for action

As in England, reforming social care is currently a top priority in the other UK countries. Experience suggests that success will be enabled by effectively engaging the public in genuine debate and creating a vision that offers certainty and clarity to all.

But what is clearest of all is that reform of service delivery and reform of funding must go hand in hand to form a comprehensive, coherent and sustainable programme of change. With a large Commons majority, the current government has a rare opportunity to grasp the nettle and put in place the foundations of an enduring and much-needed system.

Suggested citation

Oung C (2020) "Social care across the four countries of the UK: what can we learn?”, Nuffield Trust comment.