The unsolved puzzle of adult social care
Researcher
It is no secret England’s adult social care system is in crisis. Chronic underfunding, regional disparities in access to and quality of care services, and ever-growing unmet demand is the unfortunate reality. This is not simply a policy or economic issue, it’s a moral one. Radical redesign is desperately needed.
Yet what England has seen is decades of governments promising to take bold action to fix social care, then failing to deliver and ultimately kicking the can down the road. It’s essential Labour’s manifesto commitments to reform social care and create a ‘National Care Service’ amount to more in practice than the promises of governments past.
Labour’s first step towards this has been launching the Casey Commission earlier this year, set to deliver a plan to implement Labour’s National Care Service in 2026 and report longer-term recommendations to transform adult social care by 2028.
This is the third independent commission on social care reform in England in so many decades. Some fear the Casey Commission is a substitute for the urgent action that the funding model and sector needs now.
Others, recognising the need to get this reform right and feeling this Government is uniquely positioned to make lasting impact, have praised the Commission’s launch. Anna Dixon MP, Chair of the All-Party Parliamentary Group for Carers, described the commission as “a once-in-a-generation opportunity to reshape how millions of us will experience care”.
Either way, the Commission is underway, and it is thus an ideal time to look overseas to learn whatever we can from how other countries’ social care systems work. Spoiler: nobody has the ideal model quite figured out!
Japan: a generous social insurance model
- Eligibility: Universal comprehensive provision of social care to over-65s or disabled individuals between 40 and 65 years old.
- Funding: Half funded through general taxation, and half funded through mandatory contributions from everyone aged 40 and older plus means-tested co-payments, meaning those receiving State-funded care services are responsible for funding 10, 20 or 30 per cent of the cost of those services.
- Challenges: Financial sustainability, and reducing provision despite high spending levels.
Germany: a less generous social insurance model
- Eligibility: Universal basic social care provision for anyone with a long-term social care need. This is only partial coverage, it is expected individuals self-fund necessary top-ups.
- Funding: All income-earning adults, including pensioners, are required to make contributions of between 2.6 and 4.6 per cent of their income, with employers covering part of the cost of this contribution and childless individuals over 23-years-old paying a small surcharge.
- Challenges: Financial sustainability, despite far less generous State provision than Japan.
Sweden: a universal model
- Eligibility: Universal access for anyone working or living in Sweden experiencing sickness, disability or long-term care needs.
- Funding: Funded via regional municipal taxes and national taxes.
- Challenges: Financial sustainability and a very high tax burden.
United States: a private model
- Eligibility: Very limited State provision for long-term care, via Medicaid.
- Funding: Individuals are required to self-fund long-term care, with minimal insurance provision for such needs.
- Challenges: Vast unmet need – in 2023, 42 per cent of adults struggling with day-to-day tasks, like getting dressed, using the bathroom and meals, received no help.
The examples demonstrate no country has figured out the balance of a financially sustainable system and avoiding an unacceptable level of unmet need. Pressures are growing for every system, driven by demographic changes – a globally ageing population who are also living longer in poor health, and increasing incidence of long-term conditions in working-age adults.
In this context, difficult choices have to be made around the fairest funding model, eligibility for State support, and what an acceptable minimum level of care looks like. The trade-offs cannot be avoided.
If this whistlestop tour of the challenges facing adult social care has left you feeling somewhat deflated, do not fear. Here, at Re:State, the ‘Re:Imagining Health’ and ‘Re:Imagining the Local State’ work streams have joined forces to tackle this very issue. Expert interviewees, site visits and the devouring of academic literature will inform our recommendations.
Stay tuned for our radical-yet-implementable ideas to reform the funding and delivery of adult social care.