2 The present social care system |
11. Before we turn to examine the shortcomings
of social care and current proposals for reform, it is important
to understand the nature and broad characteristics of the present
system. In this chapter we consider:
are social care services and who are they for?
Who is responsible for social care services?
How is social care funded?
What duties and powers do local authorities
What are social care services
and who are they for?
12. Traditionally, social care needs have been
identified by classifying people according to:
or infirmity relating to age;
learning disability (developmental disorders
involving intellectual impairment, e.g. Down's Syndrome);
functional mental illness (involving
a disorder of the mind, e.g. schizophrenia or bipolar disorder);
organic mental illness (resulting from
physical impairment of the brain, e.g. dementia or brain injury).
Social care services have conventionally sought to
meet care and support needs through publicly provided or commissioned
residential and non-residential services, the latter including
domiciliary care, meals-on-wheels and day centres (see Annex 1).
13. In recent years, however, these ways of understanding
and organising social care have been strongly criticised by people
who use services themselves. Traditional services, and categorisations
of people who use services, have been recognised as often unhelpful,
and even counterproductive, in addressing people's actual needs
and preferences. In response to this critique, and reflecting
shifts in political thinking about public service delivery, new
approaches to providing social care have been introduced as part
of "personalising" care and support (this is explored
more fully in Annex 2).
14. The Department of Health (DH) now uses a
broad "enabling" (as opposed to prescriptive) definition
of social care as:
the wide range of services designed to support people
to maintain their independence, enable them to play a fuller part
in society, protect them in vulnerable situations and manage complex
Since 1997, some groups of people who are eligible
for social care have been able to choose to receive Direct Payments,
i.e. cash sums that they can use to meet their needs, in lieu
of non-residential services that are publicly provided or commissioned.
These payments are often used to employ Personal Assistants (PAs),
who help in a wide range of ways with care and support needs.
Further innovations that allow greater choice and control for
people who use services are also being rolled out, notably Individual
Budgets and Personal Budgets, (giving people control over the
budgets allocated for their care and support, without necessarily
receiving cash payments). At present, these alternative modes
of social care provision only exist on a relatively small scale,
but they are seen as having the potential to transform beyond
all recognition the landscape of social care, as we discuss in
detail in this report.
15. Official data returns for adult social care
in England show that in 2008-09:
total of 1.78 million people received care and support;
1.54 million people received non-residential
care and support;
319,000 people received residential care
86,000 social care clients received a
28,000 carers of adults aged 18 and over
received a Direct Payment.
16. This publicly-organised social care is modest
in scale compared to the very large amount of care and support
provided by "carers", i.e. people who provide unpaid,
voluntary care and support, such as spouses, partners, family
members, friends or neighbours.
Who is responsible for social
17. Adult social care falls within the statutory
remit of the 152 Councils with Adult Social Services Responsibilities
(CASSRs), an arrangement
that dates back to the National Assistance Act 1948.
How is social care funded?
18. In 2008-09 total gross current (i.e. non-capital)
expenditure on Personal Social Services (PSS)
amounted to £16.1 billion.
This represents an increase of over £791 million on the 2007-08
figure of £15.3 billion (approximately 3% in real terms).
Overall gross expenditure on adult PSS rose in real terms by 57.4%
between 1997-98 and 2007-08.
This is in contrast to spending on the NHS, which doubled in the
same period; however, social care is funded on a different basis
to the NHS, through a mixture of local and (mostly non-ringfenced)
national sources, as we explain below.
FUNDING FROM CENTRAL GOVERNMENT
19. Most funding for social care comes from central
government through the (non-ringfenced) Revenue Support Grant
(RSG). Central Government
also pays specific grants, which are now mostly included in the
Area Based Grant. The RSG allocation for each council is calculated
using Relative Needs Formulae (RNFs). The RNF for older people's
social care takes account of social structure, area costs, levels
of deprivation and numbers of older people (particularly the "older
old", aged 80 or over).
20. Overall, total Aggregate External Finance
(AEF) for local authorities (i.e. all moneys distributed to them
by central government) rose by 4.2% in 2009-10. The AEF increase
for 2010-11 will be 4%; grants to local government will then have
risen in real terms by 48% since 1997-98.
However, it is clear that, given the current state of the public
finances, settlements for some years thereafter will be much less
LOCAL SOURCES OF FUNDING
21. A substantial proportion of social care spending
comes from finance raised by councils themselves. The Local Government
Association (LGA) told us that in 2008-09 councils' combined net
contribution to social care spending amounted to £5.3 billion
(i.e. 32.9% of the provisional total gross current expenditure),
with some councils spending more on social care than the value
of their entire RSG.
Councils do, though, differ significantly in their willingness
and ability to raise revenue for this purpose. Most of the funds
raised locally for social care come from levying Council Tax,
subject to the constraints imposed by the Government's power to
"cap" Council Tax increases.
22. Local authorities have a good deal of choice
in how they spend their available funds, subject to the government
spending cap, as
well as requirements on spending ringfenced government grants
and meeting statutory obligations (which only apply in limited
ways to social care). There are many competing claims on council
budgets and the amount spent by each local authority on social
care will to a large extent reflect how much priority it is given.
23. Councils can offset significant amounts of
their gross expenditure on social care by levying charges on some
people who use services, subject to the constraints imposed by
national rules. This is discussed further below.
What duties and powers do local
24. Local authorities have certain statutory
duties and powers regarding: the provision of information; the
assessment of need for social care services; and the provision
of support to people who meet local eligibility criteria.
PROVISION OF INFORMATION
25. Councils have a legal obligation to provide
information about non-residential services. In cases where people
are not able to access council-arranged services, local authorities
are expected to signpost appropriate alternative provision.
ASSESSMENT OF PRESENTING NEEDS
26. Each CASSR has a statutory duty to carry
out an assessment of a person's "presenting needs" for
social care services in certain circumstances.
There is also a duty to notify NHS and housing support authorities,
and to invite them to take part in the assessment process where
it appears there may be a need for their services. In addition,
carers aged 16 or over who are caring for a person aged 18 or
over who uses social care services are entitled to a separate
assessment of their ability to provide, or continue to provide,
ASSESSMENT OF ELIGIBLE NEEDS
27. Councils have the discretion to determine
which needs are "eligible needs", i.e. which level of
need will qualify a person to receive care and support. Since
2003, eligibility has been assessed by councils according to a
set of four standard threshold criteria, laid down in mandatory
Fair Access to Care Services (FACS) guidance (see Box 1). This
was issued by the DH partly in response to concerns about the
perception of unfair and unjustifiable variations between local
areas (often referred to as a "postcode lottery").
Box 1: Summary of Fair Access to Care Services
standard threshold criteria
|1) Critical - where life is in danger, or serious abuse or neglect has occurred or might occur;
2) Substantial - where abuse or neglect has occurred or might occur, or the individual is unable to carry out the majority of personal care (i.e. activities such as washing, dressing, going to the toilet, eating, etc.) or domestic routines and there is no-one available to assist;
3) Moderate - where the individual is unable to carry out several personal care or domestic routines, or several of their family and social roles;
4) Low - where the individual is unable to carry out one or two personal care or domestic tasks, or one or two of their family and social roles.
28. The FACS guidance does not:
which needs should be regarded by councils as eligible;
require councils to make identical decisions
about a particular person's level of need (should someone present
for care and support in more than one council area); or
prescribe what services should be available
to people with similar levels of need.
PROVISION OF SERVICES
29. Where eligibility criteria are met, councils
have a duty:
to provide residential accommodation for persons
aged 18 or over who by reason of age, illness, disability or any
other circumstance are in need of care and attention not otherwise
available to them.
In addition, councils have the power under the 1948
Act to arrange or provide non-residential services as they think
appropriate for adults:
who are blind, deaf, or dumb, or who suffer from
mental disorder of any description, and other persons aged 18
or over who are substantially and permanently handicapped by illness,
injury, congenital deformity or such other disabilities as may
be prescribed by the Minister.
There are also some statutory obligations in this
regard under the Act and subsequent legislation. In respect of
each person for whom care and support are to be commissioned or
provided, a written Care Plan should be prepared.
30. In providing non-residential care and support,
councils are required to offer Direct Payments in lieu of any
social care services to meet the assessed needs of people, provided
they have been assessed as willing and able to manage Direct Payments
(either alone or with support). Direct Payments cannot be used
provided directly by the local authority itself;
permanent residential accommodation;
employment of a spouse/partner or co-resident
any spending that is not intended to
meet the assessed needs of the person using the service.
MEANS-TESTING AND CHARGING
31. Unlike healthcare, social care services are
subject to means-testing and charging. This particularly affects
services for older people, where £1.8 billion (20% of gross
expenditure) was recouped in client contributions (made up mainly
of charges) in 2008-09
(compared to around 6% of gross expenditure on services provided
to working age adults).
The regimes under which this occurs differ between residential
and non-residential services, as we outline below.
Means-testing and charging for residential care
32. There are statutory national rules, which
originated under the 1948 Act, concerning means-testing and charging
for residential care services.
Each local authority has a "standard rate"
it will pay when it places a person in residential accommodation,
according to the type and level of care needed. This sum covers
personal care and "hotel costs" (i.e. accommodation,
food, laundry, etc.).
The council is required to carry out an assessment of the resident's
financial means (both assets and income), charging them such sums
as they are liable to pay.
33. The means test relating to assets covers
cash, investments, property (including equity in the resident's
own home) and other capital. For the first 12 weeks after entry
into a care home, the value of a person's principal property is
not included in the means test (i.e. it is "disregarded").
Thereafter, it is included, except where a current spouse/partner
or other qualifying person
continues to live there, in which case it continues to be disregarded.
34. A person with total (non-disregarded) assets
worth more than a given capital threshold (this is uprated annually
and in 2009-10 stands at £23,000) receives no public financial
support. In this case, the resident must pay the full standard-rate
amount for their council-arranged care (i.e. pay a 100% charge);
or they can choose to make their own private arrangements (usually
known as "self-funding"). The resident will only qualify
for public support when the value of the assets has been spent
down to the level of the disregard threshold. This often means
that property has to be sold and much of the proceeds spent on
paying for residential care.
35. People with assets below the £23,000
threshold (in 2009-10) receive public support, but are required
to pay almost all of their "assessed income" in charges.
All pension income (both state and private)
and most social security benefits
are included in the assessed income. For people with assets below
the £23,000 threshold and above a lower capital threshold
(this is also uprated annually and in 2009-10 stands at £14,000),
a "tariff income" is assumed from capital above the
lower limit. Currently (in 2009-10) the rate for this is set at
£1 per week for every £250 or part thereof.
36. The only part of assessed income that does
not have to be paid in charges is a modest weekly Personal Expenses
Allowance (PEA); this figure too is uprated annually and in 2009-10
stands at £21.90.
The DH states that the PEA "is intended to enable residents
to have money to spend as they wish, for example on stationery,
personal toiletries, treats and small presents for friends and
Means-testing and charging for non-residential
37. Councils have the power to means-test and
charge for non-residential care as they see fit, within the Fairer
Charging guidelines issued by the DH in 2003. These state that
any capital threshold for the purpose of means-testing for domiciliary
care should not be lower than that for the residential care means
test (as outlined above). Equity in a person's principal property
(i.e. the value of their home) cannot be included in the means
test for non-residential care, in contrast to the means test for
38. The guidelines also specify that a user's
assessed net income after care charges must not fall below a minimum
threshold; and they forbid charging a minority of people who use
services who fall into certain categories. There is a great deal
of variation between local authorities in their operation of charging
for homecare services. A small number of councils choose to provide
free services for all or for certain groups of people. Some charge
a flat rate (i.e. it applies to all, irrespective of relative
ability to pay) to those who fail the means test; this is a highly
regressive policy, imposing the greatest relative burden on those
who are relatively worst off. Most councils, however, levy "stepped"
charges, with a series of means thresholds to take account of
relative ability to pay.
39. As this chapter has shown, the social care
system is complex and confusing. This system is likely to come
under increasing pressure to meet people's needs as a result of
anticipated changes in demand and costs. In the next chapter we
consider the evidence for this and its implications for the future
of social care.
8 Department of Health, Our health, our care, our
say: a new direction for community services, Cm 6737, January
2006, para 1.29. Adults social care helps people aged 18 and over.
The term "community care" was widely used in the past
to describe social care but it is less common now, although it
remains embedded in social care legislation. Back
These are provisional data. There is an element of double-counting
within and between the categories of non-residential and residential
care recipients, as some people will have used more than one type
of service during the year; the total figure for all care recipients
(1.78 million) does not include any double-counting (Health and
Social Care Information Centre, Community Care Statistics: Social
Services Activity, England - Councils with Adult Social Services
Responsibilities tables, provisional, 2008-09). Back
HC Deb, 18 January 2010, col 115W Back
The term "informal care" is often used to describe this,
but it is not universally accepted. Back
CASSRs are enumerated as follows: Unitary Authorities (55); Metropolitan
Boroughs (36); London Boroughs (32); County Councils (27); the
City of London Corporation; and the Council of the Isles of Scilly. Back
The term "Personal Social Services" mainly encompasses
social care, but also includes other services. It is generally
considered anachronistic but remains in administrative use. Back
Provisional data from the National Adult Social Care Intelligence
Service, nascis.ic.nhs.uk Back
Health and Social Care Information Centre, Personal Social Services
Expenditure and Unit Costs, England Provisional 2008-09; cf.
Q 3 Back
Health Committee, Public Expenditure on Health and Personal
Social Services 2009, HC (2009-10) 269-i, Table 34b Back
RSG is paid as part of the Formula Grant, along with National
Non-Domestic Rates (a business tax that is levied nationally and
then allocated to local authorities on a capitation basis. Back
Calculation by the House of Commons Library, using data from the
Department for Communities and Local Government Back
Ev 26 Back
Central Government allocations to local authorities are adjusted
(by means of calculating Relative Resource Amounts) to take account
of local authorities' differing abilities to raise money from
local taxation on account of varying local taxbases. The Government
has deemed that, in 2009-10, any Band D Council Tax increase of
more than 5% is excessive. Back
The Government's capping regime limits budget requirements (i.e.
spending financed by Formula Grant and Council Tax). In 2009-10,
authorities' requirements have been deemed excessive if they set
an increase of more than 4%. Back
The circumstances are where: the person appears to be someone
for whom social care services could be provided; and the person's
circumstances may need the provision of some social care services. Back
National Assistance Act 1948, section 21 Back
Ibid., section 29 Back
Client contributions also include a small amount of revenue raised
through sales and fees. Back
Provisional data from the National Adult Social Care Intelligence
Service, nascis.ic.nhs.uk. Central government allocations to local
authorities are adjusted, by means of the Low Income Adjustment
in the Social Services for Older People RNF, to recognise authorities'
differing abilities to raise income from charges. Back
These rules are now embodied in the National Assistance (Assessment
of Resources) Regulations 1992 and the Charges for Residential
Accommodation Guide. Back
This is also sometimes called the "usual cost". Back
Nursing care provided as part of a package of care in a nursing
home is paid for by the NHS. Back
Other qualifying persons are: a person under the age of 16 whom
the property owner is liable to maintain; a close relative over
the age of 60; a close relative under the age of 60 who is disabled;
or an estranged partner who is a lone parent. Back
Councils also have discretion to disregard the value of a property
if a carer is still living in it when the owner moves into a care
Half the value of a private pension is disregarded if it is being
paid to a spouse or civil partner who is not living in the same
care home. Back
The mobility component of Disability Living Allowance is excluded
from the means test. Back
The tariff income formula is not intended to represent any actual
rate of return that could be obtained from investing or depositing
capital at current interest rates. It is an administrative device
for setting user charges applicable to people with a certain level
of assets. Back
A resident would only be completely absolved from paying charges
if their income were below the level of the PEA; but this should
not happen if Pension Credit is claimed from the Department for
Work and Pensions. Back