32.Agreeing principles can play a valuable role in building consensus on difficult topics, facilitating decision-making and engaging the public in a debate. For example, following a process of ranking, prioritisation and voting, the Citizens’ Assembly developed a set of values and principles which the members referred to when making their own decisions and recommended should underpin decisions about funding social care.
33.Many of the written submissions we received set out principles which it was suggested should be the foundation for social care reform. For example, ADASS said that “the debate about how we fund social care should be informed by a clear and coherent set of principles about the purpose of a modern adult social care system and what it is designed to achieve”. Their 12 principles touch on many aspects of the system, from the need for care and support to be centred on the needs and wishes of the individual to funding sufficient for the whole quantum of need, and carers’ rights.
34.The Government is also approaching reform in this way. Earlier this year, in March 2018, the Secretary of State for Health and Social Care, Jeremy Hunt, outlined “the seven key principles that will guide the Government’s thinking ahead of the social care green paper”. Deciding to follow suit, we have developed our own set of principles which have a particular focus on funding. Our principles should build on those already articulated by the Government and inform and direct the forthcoming discussions about how to raise funding for social care and how it should be used. In addition, they underpin the funding recommendations we have set out in chapter three.
The seven key principles outlined by the Secretary of State for Health and Social Care in March 2018 are:
1.Quality and safety embedded in service provision;
2.Whole-person, integrated care with the NHS and social care systems operating as one;
3.The highest possible control given to those receiving support;
4.A valued workforce;
5.Better practical support for families and carers;
6.A sustainable funding model for social care supported by a diverse, vibrant and stable market; and
7.Greater security for all—for those born or developing a care need early in life and for those entering old age who do not know what their future care needs may be.
35.In the words of one of our witnesses, “We need to tie any future funding to a genuine conversation about what the system is there to achieve for people and make sure that it really delivers”. We agree, and make the further point that funding should be sufficient to ensure that the care provided to people is of good quality, meaning it achieves the aims of social care in promoting a person’s wellbeing, independence and dignity, and their ability to exercise choice and control. This principle was also identified by the Citizens’ Assembly; they wanted a funding solution that would ensure care was high quality, fair and equal and that, in accessing care services, people were treated with respect and there was no postcode lottery. With regards to quality, the Assembly members said:
The funding solution should enable “consistently high quality” social care. Assembly Members stated that “people have a right to quality care” and suggested needing to “increase funding to match the quality of care we want”. To ensure quality, Assembly Members suggested the need for “trained and professional workforce, higher pay, improved inspections, improved assessment [and] increased staffing levels”.
They also said that, alongside more investment in the system, they would expect “a better service”, suggesting that more needed to be spent on the workforce, carers and prevention: “How it is going to be spent is as important as how it is going to be funded.”
Funding should be sufficient to achieve the aims of social care, which are to promote a person’s wellbeing, independence and dignity, and enable them to exercise choice and control over the way their live their life. This will require universal provision of high quality, personalised care delivered by a stable well-paid and well-trained workforce alongside well-supported carers to a wider group of people than currently receives care, all within a navigable and accessible system. It should also aim to address the current levels of unmet and under-met need.
37.The Green Paper will focus solely on social care for older adults, with policy on social care for working age adults to be developed though a “parallel process”. We heard this division strongly contested by organisations representing working age adults with care needs, as well as those representing older people. Neil Heslop, Chief Executive of Leonard Cheshire, which represents working age adults, said “There is real concern that splitting [the groups] risks not delivering an outcome for both communities appropriately”. The Citizens’ Assembly members also had a strong preference for joining up the social care reform process for working age adults and older people.
The social care Green Paper is focusing on older people. However, provision of care for working age adults amounts to over half of all spending on social care and is set to grow in future years. To be sustainable, reforms to social care funding, including decisions on where the funding should come from, need to take into account the costs of meeting the needs of working age adults. At the very least, the Green Paper should be closely linked with the parallel programme for working age adults, clearly setting out how its proposals impact on funding for that age group. The Green Paper should consider both.
39.The evidence we heard revealed that, for a funding solution for social care to be perceived as fair across the generations, it would have to reconcile different attitudes across the age groups. These included the feeling among older people that they had “worked hard during their lives, paid their taxes, paid into the system and it ought to be there for them when they need it in later life”. On the other hand, while recognising that not all older people are wealthy, in general older people’s wealth relative to younger generations was seen as having increased in recent decades, with the current generation of young people being “the first to be worse off than their parents”, with many facing an extended period of paying in effect a “graduate tax”. The further point was also made that, as older people will benefit from social care reforms, “it would be reasonable to expect [them] to make some contribution”.
Intergenerational fairness needs to be addressed. Contributions towards the cost of care should be fairly distributed between generations. Some older people who stand to be the main beneficiaries of increased spending on social care may be relatively wealthy, with housing assets, savings and pensions, compared to younger generations. Young people often face higher housing costs, less stable employment and less generous pensions, and may be paying back student loans or have family commitments. Life expectancy has increased, which is a cause for celebration, but which again has implications for the balance of contributions between different age groups. Working age employed adults are a shrinking proportion of the total adult population. For these reasons, older people could be expected to continue, while taking into account the fact that they have contributed throughout their working lives via taxation. However, over the longer term, the distribution of wealth between the different age groups may change, with corresponding implications for fairness, suggesting that a flexible solution is required.
41.Currently, the greater part of the burden of the costs of care is shouldered by individuals. For dementia sufferers, who can face care costs of £100,000 to £500,000, this results in great unfairness, particularly when other long-term health conditions, like heart disease or cancer, are treated within the NHS free of charge. Dominic Carter of the Alzheimer’s Society told us that “We need to move to a point where the balance of responsibility is clearer […] but is also fairer between the individual and the state”. The Dilnot Commission recommended a more generous means test and a cap to divide the costs of care more fairly between older people and the state and that individuals who enter adulthood with care needs should receive free state support (a ‘zero cap’). This approach was accepted in principle by the then Government and legislated for in the Care Act 2014, but the relevant part of the Act has not yet been implemented. The Citizens’ Assembly wanted to go further than this; two thirds of the members voted for an entirely publicly funded system as their first preference, and we set out their reasons for this conclusion in chapter four. While this would of course substantially increase costs, we believe that it should be the aspiration for social care in the long term and that this principle should be borne in mind when considering future funding. In the short term we feel that at least those assessed as having critical need for social care should receive this free at the point of delivery.
Currently, the burden of the cost falls on individuals in an unfair distribution depending on diagnoses—particularly those paying for dementia care, the costs of which can be extremely high. The balance needs to be redressed, aspiring over time and moving towards, as funding permits, universal access to sustainably funded social care, free at the point of delivery.
43.Currently people who have high social care needs can face catastrophic care costs—there is currently no way of insuring yourself against these risks. A more generous means test (or ‘floor’) and a cap would divide the costs of care more fairly between older people and the state. These mechanisms would also protect people from catastrophic care costs and protect a greater proportion of their savings and assets. Providing free at point of delivery care for those with high care needs would be another way of protecting people from this risk.
People want to be protected from the lottery of incurring catastrophic care costs, and to feel secure that they will be able to keep a greater proportion of their savings and assets. A cap on the amount of care costs a person paid would pool the risk, distributing the costs of very high care needs across the society. The level of protection (and therefore the costs of this policy) would depend on the level at which the cap is set, and determining this figure requires financial modelling and extensive consultation. Raising the means test threshold (the ‘floor’) is another way of enabling people to keep a greater proportion of their assets; again, the costs would be shared across society. Providing free at point of delivery care for those assessed as having critical or substantial care needs would be another way of protecting people from this risk.
45.‘Hypothecation’—or ring-fencing taxation to a specific purpose—is often proposed as a way of raising more funding for social care. We prefer to use the more easily understandable term ‘earmarking’. While tax rises are generally not popular with the public, clearly linking them to a specific purpose can build support and acceptance for them. The views of Citizens’ Assembly members, two thirds of whom voted for additional social care funding to come from earmarked taxation as opposed to general taxation, reflected this. However, the weaknesses of this approach should also be borne in mind. If the ring-fence is rigidly drawn, the tax take will rise and fall with the economy over time and not be aligned with changes in need or demand. However, any degree of flexibility risks the revenue not being used for its original purpose—we note the examples of earmarked taxes which have been introduced for a specific purpose but have later been subsumed into the pool of general taxation, for example, Vehicle Excise Duty and National Insurance.
People are generally willing to contribute more to pay for social care if they can be assured that the money will be spent on this purpose. ‘Earmarking’ taxation can help to give confidence and accountability over spending.
90 See, for example, CIPFA (); The Local Government Association (); ADASS (); United for All Ages (); Sense (); Leonard Cheshire Disability (); Inclusion London ()
91 ADASS ()
92 Department of Health and Social Care, (20 March 2018)
94 HC Deb, 16 November 2017, [Commons written ministerial statement]
95 For example, Caroline Abrahams at
97 . See also
98 CIPFA ()
99 United for All Ages ()
104 Department of Health and Social Care, (17 July 2015)
Published: 27 June 2018