- Although the systems in all four countries have diverged, it is clear that no UK country has adequately solved the ‘problem’ of social care. All are on the brink of reform, but it is unclear at this point if they will diverge further.
- While tangible reform to the system has remained persistently elusive in England, Wales has actively been trying to promote wellbeing and better integration of health and social care through various initiatives. Northern Ireland’s ongoing political turmoil has been an obstacle to reform, although a recent power-sharing agreement might mean some movement in the near future. Scotland is the most advanced of the countries in its reform plans, having set out an ambitious and comprehensive vision for a social care service.
- Perhaps what unites all countries is their struggles with funding. Without significant new levels of funding, supported by a sustainable funding mechanism, it is unlikely that any ambitions for reform in any of the countries will be realised.
While many of the challenges across the four countries are shared, each has responded to these in different ways. We address these in an accompanying blog that identifies what England could learn from its UK neighbours.
Here we discuss the main policy developments under way in each country in turn.
The implementation of the most recent legislation around social care, the Care Act, was delayed. Following this, a green paper for reform was initially promised for 2017. This has now been delayed multiple times, reportedly due to internal disagreements over funding reforms and a failure to achieve a cross-party consensus. Recommendations for reform have been put forward from stakeholders at all levels, including individuals and service users in the form of a Citizens’ Assembly report, local government and various political figures.
The current government has promised to find a “long-term solution on social care” that commands “cross-party consensus”, and which would “provide everyone with the dignity and security they deserve” while protecting individuals from losing their homes. In January this year, the Prime Minister promised a plan for reform in the coming year, and that these changes would be enacted under the current parliament. However, in the same statement, Mr Johnson reiterated that plans would be focused on giving people the care they need “in old age”, which raises concerns about reform to care for working-age adults. In early March, the Secretary of State for Health and Social Care Matt Hancock wrote to all MPs asking for their views and collaboration over social care reform.
The Social Services and Wellbeing Act, legislated shortly after England’s Care Act, is being evaluated over a three-year period – the preliminary results of which were published in 2019. As well as the Act itself, other pieces of legislation in accordance with the Act – such as 2015’s Well-being of Future Generations Act and the Regulation and Inspection of Social Care Act 2016 – have maintained its principles of wellbeing, community development, co-production and prevention, and further cemented its implementation. Stakeholders have suggested the coherence of these acts has been facilitated by strong leadership from the Welsh First Minister, who has a background in social care.
In 2018, the Welsh government’s published A Healthier Wales: our plan for health and social care. This was supported by a transformation fund to help the development of collaborative (“co-operative”) pilot projects in health and social care, led by multi-agency regional partnership boards. By January this year, £89 million had been allocated for proposals across Wales, although progress has been slower than expected due largely to recruitment and procurement issues. A lack of substantial recurring funds is also suggested to have hindered the extent to which reform is possible, with stakeholders suggesting creative innovation has arisen out of necessity rather than by top-down direction. Moreover, the Wales Audit Office recently published a report on the Integrated Care Fund, an initiative designed similarly to support integrated working and new care models involving health, social care and the third sector. The report found little evidence of successful projects being mainstreamed into core budget or improving service outcomes.
Measuring the mountain, a report on citizens’ views of social care in Wales, was published in 2019 and supported by the Welsh government.It suggests current implementation of the Social Services and Wellbeing Act has not been sufficient to resolve many problems in social care, particularly around access to information and support, the workforce, and support for carers. The report recommends a continued emphasis on co-production between local authorities, service users and carers to develop a shared vision for social care.
The Welsh government has investigated alternative ways of funding social care, including the publication of Paying for social care, in which proposals for an age-related levy were raised for debate in the last year. No firm proposals have so far been tabled, but the levy is being considered alongside income tax rises, and changing fees will form part of a consultation beginning this summer. It is unlikely that any formal proposals will be brought forward until after the Welsh elections in 2021.
Scotland has embarked on a comprehensive programme of reform in social care that was launched in June 2019. The programme is driven by research commissioned by the Scottish government. It aims to represent all stakeholders in social care through co-production mechanisms, via the People-led Policy Panel that represents individuals with experience of receiving social care (as well as their carers), and the Leadership Alliance that brings together key leaders in the provision, regulation and delivery of social care.
The vision for a complete reform of the social care system has been developed by key stakeholders in the sector, including regulators, providers and the government. It is centred around five key themes: human rights-based approach to social care, access to support, types of support, decision-making processes, and consistency across Scotland. In parallel, the Self-Directed Support Implementation Strategy continues to be implemented over 2020/21. Over the next year, the Scottish parliament is also considering the development of a new financial scheme for social care, as well as improved data collection.
Stakeholders suggested all changes in Scottish social care were moving in the same direction due to the complementarity of legislation. However, while the vision was felt to be ambitious, it was suggested current funding settlements would not be sufficient to enact the entirety of planned reform, and that plans for new funding mechanisms were not yet sufficiently developed.
Other reforms affecting the social care landscape have included the introduction of Frank’s Law in April 2019, under which free personal care was extended to all adults. However, it was reported that only a third of under-65s stood to benefit from this extension.
At the time of writing (January 2019), Northern Ireland had only recently found a power-sharing agreement in, having previously been without an Assembly since 2017. As such, plans for reform such as Transforming Your Care and Power To People have lacked the necessary strategic and statutory backing to be enacted. Many other pieces of legislation, such as the Carers and Direct Payments Act in 2002 (many others were enacted over 40 years ago), are largely regarded as outdated by key stakeholders such as the Commissioner for Older People in Northern Ireland., As such, many changes to service delivery, such as the progressive roll-out of self-directed support, do not appear in legislation but rather in policy.
A new, shared power agreement in the New Decade, New Agreement proposal has committed to the implementation of the Transforming Your Care and Power to People policy proposals, which may lead to more active transformation in the future.
Stakeholders reported that an implementation strategy for a social care-wide reform was being developed and due to be published in late 2019 or early this year, with topics such as workforce and informal carers also being addressed. At the time of writing this is unpublished.
Given the lack of statutory change in both health and social care in Northern Ireland over the past few years, the system is on the brink of collapse. One of the big challenges specific to the country will be sustaining the delivery of free domiciliary care without a significant change in how funding is distributed.
Oung C, Curry N and Schlepper L (2020) 'What steps are currently being taken to reform social care'?, in Adult social care in the four countries of the UK. Explainer series, Nuffield Trust.