The debate about the future of social care tends to focus on funding options. In the last few elections, whenever social care has featured in campaigning it’s all been about money. Rumour has it that the green paper is delayed partly because of disagreement over funding. It’s politically tricky and potentially divisive. Next week, we will publish a round-up of all the proposals for funding to date and reflect on what principles might underpin an effective financing system.
But, while the way care is paid for is undoubtedly important, it’s not the whole story. Before we delve into the intricacies of the funding options, I want to take a step back and ask what should a ‘good’ social care system look like for those who use it.
A flawed system
Ask anyone who has had to navigate the social care system in recent years – maybe to secure a care package for an elderly relative or a disabled adult – and chances are it won’t be just the lack of state funding available but a whole array of other issues that plague this deeply flawed system.
Besides the costs, what can also come as a shock is the amount of perseverance and energy it takes to navigate this labyrinthine system. First contact with the system is frequently at a time when a person or a family is at their most vulnerable, and least equipped to deal with the complex means test and eligibility criteria that can vary hugely from place to place.
“Postcode lottery” is a phrase frequently attached to public services, but arguably never more apposite than in relation to social care. Despite attempts in the Care Act to create a national eligibility criteria – intended to ensure that local authorities must meet the needs of people who meet a standard minimum threshold – it remains just that: an absolute minimum, and some local authorities have still struggled to meet their responsibilities. As a result, provision and access are hugely varied, so it is not your needs that ultimately determine what state support you are eligible for, but rather your postcode.
The distinction between health and care creates a further inequity: someone deemed to have health needs can access care via the NHS’s continuing healthcare programme, but someone with personal care needs, but no medical requirements, is subject to the means test.
For the many millions of people with care needs who are not eligible for any state support, it is not the severity of need that determines the amount and quality of care services they can access, but their bank balance. Research suggests that many millions of people are going without the care they need because they can’t afford it.
And then there’s the fragility of the provider market, which increasingly relies on cross-subsidisation between self-funders and council-funded service users to prop up struggling services. Self-funders across the country are paying on average 40% more than council-funded service users for exactly the same level of care. And because providers and councils operating in deprived areas have limited opportunities for raising extra cash, regional variations provide yet another dimension of inequity.
So, although pumping badly-needed money into the system would be a very good start, the funding solution needs to be accompanied by a whole set of reforms to how the entire system operates. While transplanting another country’s approach wholesale is unwise, our work looking at Germany and Japan has found they have both established some clear principles that we could adopt to underpin a reformed system.
1. Consistency of eligibility
A single national framework for eligibility, going far beyond anything the Care Act sought to introduce, is at the centre of care systems in Japan and Germany. No matter if you live in Berlin or Bonn, Nagoya or Nagasaki, you know that you will undergo the same eligibility test.
The tests look purely at need. It is immaterial whether a person’s needs arise as the result of physical illness or dementia, or whether someone lives alone or with family. At the conclusion of the assessment process, each individual is assigned to a level on a multi-point scale of need. This consistent approach has helped to embed high levels of public trust in the system in both countries.
2. Clarity of benefits
The level of need determines the level of care benefit an individual is entitled to. Importantly, in both Germany and Japan, this benefit is allocated on a monthly basis and is consistent across each country. There is no talk of means tests, lifetime allowances or complex caps and floors.
This clarity of benefit is matched by the clarity of contributions – also paid on a monthly basis out of income or pensions – and offers a high degree of transparency. Clarity over what people are paying in and getting out helped to secure ongoing high public support for the systems in both countries.
3. Stability of provision
Japan and Germany have adopted a fee schedule to ensure stability of the care provider market. Similar to the tariff in the NHS, the schedule specifies the amount that a provider will receive for a service user at each level of need. That schedule is fixed for a period of time (in Japan it is three years), which offers certainty and enables providers to plan and invest. Japan’s government has used this mechanism actively to shape the market, encouraging new entrants into markets where provision is lacking or incentivising innovative community-based care over residential care.
4. Sustainability of the vision
Demographic pressures are set to peak around 2040-50, and Germany and Japan have recognised the need to consider the long-term sustainability of their systems, including how they will ensure they have sufficient workers to deliver services. Social care does not operate in a vacuum, and its sustainability depends on it working alongside all other public services in the long term.
A failure in the social care system has a knock-on effect not just on health, but also on housing, employment, benefits, policing and the wider economy. Japan is investing heavily in prevention, reducing isolation and keeping people well, within a wider policy of creating communities that support older people to live independently. Germany is endeavouring to join up policy across government departments to ensure its army of informal carers, on which its system relies, are better supported to remain in employment.
The design of a country’s social care system says a lot about that society’s values and trends, and so it follows that each country’s system will differ. No system is perfect and Japan and Germany certainly have their challenges – we can learn not just from their successes but also from their imperfections.
While our system will look different, the principles upon which Japan and Germany’s systems are built – consistency, clarity, stability and sustainability – are transferable and provide a helpful framework for us as we reform our own system of care.
It would be a serious indictment of our society if the long-awaited green paper fails yet again to fully grapple with this issue. After all, how can we measure a society if not by how it treats its most vulnerable?
*Please look out for our upcoming blog on the principles that should underpin an effective funding system for social care.
Curry N (2019) "What should a good social care system look like?”, Nuffield Trust comment.