What should be the role of the state in providing and funding adult social care for older people?

As a senior social care manager put it, "How can we abandon people with high needs to invest in prevention? That is our biggest dilemma."

Examples of the difficulties people have in navigating the system:

It’s a long process. I’ve gone through it with my dad. It can be months before anything happens and you need it. Then, it’s means-tested. It gets passed to departments and then social services and you wonder if it’s worth it. (Kings Lynn workshop)

Like I say, even just getting a button [personal alarm], there’s so much red tape to go through just to get it. It’s not easy to get support. (Leeds workshop)

As a result of funding cuts*, the proportion of older people who received social care support organised by English local authorities fell from 10% in 2005/06 to 6% in 2013/14. One result has been a rapid growth in the number of people who pay for their own care (so-called self-funders).

I think it’s an improvement. It’s simple, and it’s for everybody, and it’s a basic level. (Leeds workshop)

It’s fairer. In Scotland, the number of people getting personal care grew significantly once the policy was introduced. This suggests that the system is providing care for people whose needs were previously unmet.

Helping people with low needs now may prevent them developing high needs later. It may help people stay longer in their own home, delaying the need for residential care.

Finally, this approach means that eligibility for social care is the same as for health care. This makes it easier for the two systems to work together.

Another reason for looking to the state is that more people have no children.

Where family members are involved, how far should that go? Shopping might be fair enough, but what about managing incontinence?

Here’s an example on the difficulty of relying on friends:

My good friend, she died three months ago. She had a cancer. She was very helping. Another friend and her, on Sunday they used to have lunch with me. I used to cook for them. Ah, my friend died and then, after that it’s gone. She used to help me with things, we would do our shopping together. I feel more isolated now.

(Woman in her nineties, living alone in supported living accommodation)

.And here’s an example of how helpful local authorities can be:

I’ve got to shower in my bath, and about a year ago I thought, wait a minute, anyway, I got on to social services and they supply things to help don’t they? A guy came round and put me a seat in the bath, brilliant. Sit down, do my hair and it’s all done.

(Man in his eighties living alone)

Another advantage of the current system is that it has been in place for years. Each reorganisation takes a lot of time and energy which would be better used caring for people.

This approach involves prevention: acting early to prevent significant and expensive care needs from developing. This approach can save money overall.

Here are two examples of unmet need leading to higher care needs. The focus should be on preventing those higher needs from developing in the first place.

• A lack of equipment/adaptations leading to a bad fall/injury inside the home

• People becoming lonely and isolated at home through lack of help to go out. Lacking social connections is as damaging to our health as smoking 15 cigarettes a day.

‘Catastrophic’ care costs are defined as costs over £100,000, so this is one figure that the cap could be set at.

A person with dementia can live for ten years or more: their care can cost more than £200,000. Currently, about 40,000 people a year have to sell their house to pay for care.

It has been argued that wealthier people can afford high costs. Against this, they pay more in tax, so it is fair that they be eligible for state funded social care, as they are with the NHS.

Assembly members felt that if we simply increase income tax, “people will just see it as a tax increase” and “not understand why”. Whereas, with earmarking, the public would “know where the money is going” and, therefore, that it would be more “appealing”, “sellable” and “palatable” to voters.

The only reason we’re looking at ring-fencing is because the government’s got a bad track record. So, we don’t trust them to put so much into social care. It needs to be outlined from the start. (King’s Lynn workshop)

Reducing flexibility of how government spend the money is an advantage. (Leeds workshop)

Here’s an example of how inflexible local authority social care can be:

I had the balance problem and I wasn't supposed to have a shower on my own so they [the local authority] got a social worker to come. This person couldn't do anything to help me if I had fallen. So this ended up with me paying £17.50 an hour for somebody to come and watch telly while I had a shower and the only thing that she was required to do was call 999 if I had a fall. To me that seemed a completely unacceptable way of spending money.

(Dorothy, who lives alone and has arthritis, MS and a fracture taking time to heal.)

Perhaps we should be relying more on families as a matter of principle:

"We need to start thinking as a society about how we deal with care of our own parents. Nobody ever questions the fact that we look after our children, that’s just obvious. How we look after our parents is a similar responsibility."

David Mowat, ex-health minister, 2017

A very different argument is that a cap is OK, but a cap that is the same for everyone is unfair, given the differences in social care costs across the country. For example, care can be more expensive in London than in other regions. People living in areas where social care is more expensive would be likely to reach the cap sooner than people elsewhere.

Given that it costs more, can we afford it? Are people willing to pay more taxes? Is it right that the state pays for those who could afford to pay for themselves?

A means test. It’s inevitable. There’s no way that there’s enough money in the pot. (London workshop)

Assembly Members’ concerns were that earmarked taxation was “too prescriptive”, “less flexible” and that it “doesn’t accommodate changing needs over time”.

These two quotes, from the workshops, develop the argument about inflexibiity. Of course, I disagree with it. It’s crazy. Say, you’ve got your income, in your home. You ring fence this amount for this, and you’ve got ‘X’ amount left for your car. Then your car breaks down and you can’t get it repaired, because you’ve got this money ring-fenced. (Leeds workshop)

If there are fewer younger workers, there won’t be enough to cover the costs, or do they raise the tax even more? (London workshop)

The Assembly members also had concerns about how some forms of earmarked taxation had not necessarily been ring-fenced and reserved for their nominated purpose in the past. National Insurance was given as an example.