Adult Social Care and Self-Funding: What Does a Fairer System Look Like?

This is a guest post by Silvia Miele

Self-funding in England

In the UK, healthcare is generally free at the point of delivery through the NHS, yet provision of social care is restrained by eligibility criteria and means-testing. In recent decades, the number of individuals paying for their own social care has been increasing. This is because they either do not meet the rigid eligibility criteria for access to services and/or their financial savings and assets place them above the threshold for funded care (in England this has been frozen for the past 10 years at £23,250).

Even though a considerable proportion of social care service users are self-funders, we rely on estimates to quantify the numbers involved. Indeed, different definitions of self-funding and obstacles in accessing information from providers hinder the supply of systematic data. The UK Household Longitudinal Survey (UKHLS) estimates that there were between 350,000 and 580,000 self-funders (of care home places and home care) in England in 2014. Among the four UK nations, England has the highest proportion of people paying for their own care, reflecting different policy positions on means-testing between the different countries of the UK.

Furthermore, self-funders are often wrongly assumed to be affluent consumers of social care, equipped with purchasing power giving them enhanced control and choice over the care they use. In reality, self-funders are often people (generally elderly women) with modest means, whose assets mainly consist of their home and limited life savings. They tend to desperately worry about depleting their financial resources to finance their care, and fear the potential consequences of this scenario. Indeed, when money runs out, the local authority has a duty to intervene, but often they will not be prepared to fund a place at the fees the self-funder has paid (self-funders typically pay higher costs for care home places which effectively subsidise lower fee rates paid by local authorities). As a consequence, councils might require people to relocate into a more affordable, state-funded residential care home, with all the risks and distress this can entail.

A gap in the adult social care system?

Indeed, people rarely plan in advance for their care needs, and typically decisions about care – especially entering permanent residential care – are made in times of crisis, such as following an unplanned hospital admission. For those who are not eligible for publicly funded help, an assessment of need often results in little practical support. There is a wealth of research evidence on the experiences of self-funders being given a list of care homes and other services, leaving them to find their own way in a confusing system.

While the UK central government decides the amount of money local authorities can allocate and spend on adult social care, it is the responsibility of local authorities to decide how to spend their funds. However, as they are already struggling to support those people who meet eligibility criteria, help for self-funders often dissolves as soon as they are deemed ineligible for state funded care.

This lack of guidance and information often results in rushed decisions, that do not leave room for personalised care, despite it being at the heart of national social care policies (Care Act, 2014; Health and Social Care Act 2012). These policies refer to maximising accessibility and reinforcing individual choice and control over care and support, to empower people to live independently at home for longer. However, with councils meeting only substantial and critical levels of need, many other people are left without help, contributing to the increase in unmet care need. Evidence to a 2019 House of Lords inquiry on social care funding estimated 14% of the UK population aged over 65 (1.4 million people) have unmet care needs. For people needing to buy support at home to facilitate independent living (such as help with bathing and personal care), difficulties in finding sufficient and affordable care can be considerable:

People who fund their own care and support might be thought to have the greatest choice and control of all – they can use their money as they please. In practice, the study found that self-funding people on the contrary were often the most disadvantaged and isolated in the whole system.

In search of a new system?

These issues highlight the need for a more flexible and comprehensive social care system, based on a customised, broader spectrum response to people’s needs. This could also benefit underprivileged groups whose health inequalities are replicated around social care.

Furthermore, there have been repeated calls for a longer-term vision to be engrained into a fairer system, where risks and costs are spread both at collective and individual level, rather than relying just on the latter. To achieve this, the archaic misconception that social care represents the last resort for people, needs to be shifted by reshaping eligibility criteria. Moreover, an ageing population, which is linked to an increase of complex needs and social care demand, is calling for a more integrated system between health and care services.

These issues have been magnified by the current coronavirus pandemic, which has highlighted unmet need and further destabilised the already volatile social care provider market. At the same time, it may be that this crisis will have strengthened the public’s attachment to universality of care. As a result, what better time than now to reform the adult social care system?


About the author

Silvia Miele is a doctoral researcher at the University of Surrey.

This blogpost was based on an interview with Melanie Henwood, an independent research consultant in health and social care.

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