Written evidence submitted by CIPFA [ASC 005]
CIPFA, the Chartered Institute of Public Finance and Accountancy, is the professional body for people in public finance. CIPFA shows the way in public finance globally, standing up for sound public financial management and good governance around the world as the leading commentator on managing and accounting for public money.
1.1. The need to reform adult social care funding is decades overdue – and remains one of the thorniest issues on the UK political landscape. The sector entered the COVID-19 pandemic on the back foot, facing mounting levels of demand and unmet need, workforce shortages, an increasingly fragile provider market and tightening budgets.
1.2. COVID-19 has clearly highlighted weaknesses in the sector’s resilience – and should act as a catalyst for reform. The shift in public perception of health and care services means there may never be a better time to address the relationship between state and individual, and to consider what a reformed funding system for adult social care may look like.
1.3. Here we discuss the issues and challenges involved in reforming social care funding and consider some of the proposals that have been put forward. We make no recommendations on a given level of spending, nor a particular system for organising the split between state/individual contributions, as these are political decisions. However, we do propose a five-point plan to inform the development of a sustainable and equitable system of funding to ensure the future of this vital sector.
2.1. Adult social care services are facing additional pressures and costs as a result of COVID-19, such as staffing and sickness costs, PPE and deep cleaning, to name but a few. While demand for some services has increased and will continue to do so in the aftermath of the crisis, some providers have experienced loss of income due to under-occupancy and the tragically high death rates in this sector.
2.2. More widely, local government is facing extreme financial difficulties due to COVID-19. As well as the direct costs of providing vital services during the outbreak, local authorities are facing huge income losses from business rates, council tax, fees and charges. This presents not only a cash flow problem, but has implications for their overall budget, medium-term financial plans, service transformation and savings plans.
2.3. Many of the additional costs faced by councils relate to social care, but other essential local government services have also been called upon to respond to the pandemic, including public health, shielding the vulnerable, homelessness services and children’s services. While there have been reliefs from the UK government and additional funding of £7.2bn to date, this must cover the additional costs of COVID-19 across all council services, not just those associated with social care – so this must stretch a long way.
2.4. The most recent data collected by MHCLG from local authorities on the financial impact of COVID-19 suggests that for the financial year 2020/21 total income lost will amount to £5.7bn and total additional expenditure will be £7.3bn, of which around £3.3bn directly relates to adult social care.
2.5. A recent NAO report suggests that in councils with social care responsibilities, 46% of chief finance officers (CFOs) have already used or are planning to use reserves to address COVID-19 pressures in 2020/21, and 94% of CFOs expect to cut service budgets in 2020/21. The report also shows that in these councils, service spending is increasingly concentrated on statutory services, meaning there is less headroom in which to find savings. Social care spending as a share of spending in services increased to 69% in 2019/20, from 59% in 2010/11. Adult social care is by far the greatest cost pressure facing these councils in 2020/21 relative to previous spend, with a full year forecast of over £3bn.
2.6. Despite this, councils have recognised the need to support the fragile social care provider market, as outlined in guidance from LGA and ADASS, and taken action to support providers. Councils are also administering funding on behalf of the government (from which they do not directly benefit) – for example the two tranches of the infection control fund for social care providers. This effectively pushes the onus onto councils to support the social care provider market, rather than central government directing support for this sector as they have for other areas of business.
2.7. Social care providers are also facing financial difficulties. Responding to a survey in May, 82% of local authority directors of adult social care said they had concerns about the financial sustainability of their residential and nursing care homes, and 75% were concerned about the financial sustainability of their homecare providers. In a survey of care providers conducted in late May, 64% of respondents were concerned their service was financially unsustainable.
2.8. What is clear is that adult social care was ill-prepared for responding to such a crisis. A decade of austerity, increasing demand, lack of investment and workforce issues all meant that the sector was on the back foot on entering the pandemic. These issues are explored further in our work with the Institute for Government.
3.1. COVID-19 has clearly highlighted weaknesses in the social care sector’s resilience – and should act as a catalyst for reform. The shift in public perception of health and care services means there may never be a better time to address the relationship between state and individual, and to consider what a reformed funding system for adult social care may look like.
3.2. Given the tightening of local government funding in recent years, and the fact that social service budgets are already widely over-stretched, it is essential that:
4.1. In order to develop a strategic and sustainable solution, it is critical to understand the challenges of funding adult social care. Given the many years in which action has been restricted to short-term fixes, such solutions are now more important than ever and should lead to long-term, strategically informed, financially sustainable and equitable change. It is also crucial that reforms recognise the interdependence of spending on health, public health, adult and children's social services.
4.2. We have identified some key challenges that we believe have made it difficult to respond appropriately to social care needs, and that would need to be addressed when considering future funding.
4.3. Many remain unaware that social care is not, like the NHS, free at point of care, but rather is means-tested. Publicly funded care is available only to those with care needs above a defined level and who fall within the parameters of the means test.
4.4. For residential care the parameters are set by the DHSC (with limited discretion for councils, eg around disregarding the value of the home).
4.5. It is worth noting that the capital limits have been frozen at their current levels since 2010/11. As property assets are included in the means test, many people face the prospect of having to sell their home to pay for care. Since 2015 however deferred payment agreements have been possible, where an individual does not have to sell their home to pay for care within their lifetime.
4.6. For non-residential care, councils can decide whether to charge for care, and must have a charging policy to determine access to funding towards costs of care. The means test must be at least as generous as that set for residential care.
4.7. The issue of social care funding clearly needs to be addressed at a whole population level, but this alone is not enough. While many people will require no social care at all, at the other end of the spectrum a small number of individuals will incur huge care costs. As many people self-fund the cost of their care, those who have significant care needs can potentially face 'catastrophic care costs'. In 2011, the Dilnot Commission found the median cost of care to be £20,000, but some could incur costs of £250,000. More recently, Age UK suggested that in 2018/19, some 5,190 people were classed as self-funders with depleted funds, meaning that they had run down their assets as a result of paying care costs. This represents an increase of more than 37% on the previous year.
4.8. It is a matter of chance whether long-term care needs are classed as health or social care. For example, care for an individual with cancer would be funded by the NHS via Continuing Healthcare (CHC), but that for an individual with Alzheimer's is subject to a means test. As you can see from this example, the differential is too sharp. This means that the decision on eligibility for CHC is cost-critical, both for organisations and individuals, causing unnecessary disputes.
4.9. All this suggests that social care needs to follow a pattern for which risks should be pooled – as for the NHS or fire insurance.
4.10. An ageing population that is living longer and has increasing levels of care needs means that there is increasing demand for adult social care services. However, since 2015/16 the greatest increase in requests for support have come from the working-age population.
4.11. It is also widely accepted that there is unmet need, although this is difficult to quantify. This is partly due to means testing criteria (those excluded from public funding due to their level of need not meeting the threshold) and partly due to those who do not realise they are eligible or do not come forward. This is not just a moral issue, but also relates to effectiveness – providing for lower level needs earlier may prevent deteriorating health and avoid pressures on those providing informal/unpaid care.
4.12. In recent years, local authorities have developed several strategies to assist them in managing demand, including:
4.13. Such measures have been used successfully to some degree to reduce demand (or costs) and improve outcomes and have doubtlessly helped many councils to survive austerity. It has been suggested that around 20–25% of all savings in adult social care between 2010 and 2015 were from managing demand. In this regard CIPFA have produced a framework to aid councils in providing good value across adults and children’s social care.
4.14. Real terms funding has not kept pace with demographic demand. While demand management and efficiency measures are an important part of the picture, and have enabled councils to keep services going, they will not solve the problem entirely.
4.15. Successive governments have recognised this and provided additional funding on an ad hoc basis – notably via the Better Care Fund, Improved Better Care Fund, council tax precept and social care support grant. However, these short-term measures are papering over the cracks and do not enable long-term, sustainable financial planning.
4.16. Our work with the Institute for Government on the Performance Tracker 2019 (pre-dating COVID-19) showed that if there is no change to the means and needs-tested eligibility system, demand for publicly funded adult social care will increase by around 11% by 2023/24. This means that the government would need to spend an additional £20bn to continue to provide the same scope and quality of care. This is faster than spending on adult social care has risen in recent years, and faster than local government spending power is expected to grow by 2023/24.
4.17. What is needed is a long-term view to enable planning to be more sustainable and sensibly tied to real demographic pressures. While this sounds challenging, society has already absorbed the cost of a 25% increase in the over 85s population between 2009 and 2019, and long-term social care is only a proportion of the non-pension spend, as illustrated by the projections shown below.
4.18. Some reallocation of resources would make sense, particularly when you consider that the largest areas of spend on those of retirement age – pensions, acute care and benefits – do not contribute to reducing the long-term demand for social care in the way that other spending might. So while additional spending on social care will be needed, to a certain extent this may be a matter of making choices within the existing spending envelope.
4.19. Investment decisions are critical. When budgets are tight, there is intense pressure to meet immediate need, but this approach squeezes out the preventative investment that would enable a more secure footing to be reached in the longer term. It accelerates the next crisis, which in turn requires a short-term fix.
4.20. We need to change the mindset around preventative investment. It is not only about public health, but also applies across the public services and can both improve outcomes and yield benefits such as avoidance of future costs, reduced demand for services and improved financial sustainability. We need to look at investment beyond the political cycle and measure the extent of preventative investment being made in social care and the future revenue obligations that will accumulate if such investment is not made.
4.21. CIPFA and PHE have developed a framework to improve the evaluation of preventative investments that can be applied across multiple organisations and is applicable to all public services.
4.22. Most social care services (not only residential care) are commissioned by local authorities but provided by private companies, and this market has been experiencing trouble for some time, which has only been exacerbated by COVID-19.
4.23. Spending on adult social care has increased since the low of 2014/15 (but remains below 2010/11 levels in real terms), and much of this goes to the provider market. While local authorities have tried to limit how much they pay for services, providers have been hit by increasing costs (particularly for staff as a result of the National Living Wage).
4.24. In the early years of austerity, local authorities tried to control costs by holding down the fees they paid to providers. Between 2009/10 and 2013/14 spend on residential and home care costs was cut by 8.6% and 5.3% respectively in real terms. Self-funders typically pay more for their care than those in receipt of publicly funded care, as providers tend to 'cross-subsidise'. However, an increasing number of care providers are going out of business or handing back contracts. Some have focused on services for self-funders and separated self-pay homes from those providing for publicly funded care. All of this can lead to supply problems and risks a lack of investment in services focused on publicly funded care.
4.25. The experience of COVID-19 has exacerbated the situation in the provider market. Providers of both home care and residential care have faced increased costs in relation to staffing and sickness costs, PPE and deep cleaning. While additional funding such as the infection control fund has covered some of these costs, providers have also experienced loss of income because of high death rates and under-occupancy, as those awaiting care are reticent to take up services during the outbreak.
4.26. Nowhere in the world does the private sector provide an insurance product for social care. This is not because they are unwilling, but because they cannot predict the cost curve for the current market of insurance purchasers. Costs could well be decades into the future and further shifts in patterns of spending could occur during that time. The private sector cannot take the risk of such 'aggregate shocks', so there is a complete market failure.
4.27. The key difference in public funding of social care is that the state can change the level of future funding in response to an aggregate shock, as the private sector could not. Under the current system people are forced to self-insure to a certain extent, leading to strong incentives to gaming such as gifting assets. The Care Act proposals would have addressed this to a certain extent and reduced the CHC boundary issue.
5.1. Reform of adult social care has been on the agenda for decades, and the timeline of reform to date has been a long and bumpy road. Details of some of the major milestones over the last 20 years are set out in the annex.
5.2. Between 1997 and 2017 there were: four major independent reviews/commissions, four Green Papers/major consultations, three White Papers and three Acts that made provisions for reform. Despite all of this effort, there have been no major changes to funding for adult social care. During this time there have also been numerous reports by parliamentary committees and other bodies making the case for urgent reform.
5.3. In June 2017 the government committed to bringing forward a Green Paper to address reform of adult social care funding. Four years later, proposals are still awaited. In the absence of reform, successive governments have sought to address the social care crisis via short-term injections of funding on an ad hoc basis.
5.4. While there is no shortage of policy proposals and models for reform, what is missing is political consensus and decisions on a way forward.
6.1. Many of the proposals put forward for reform of adult social care funding involve making the means test more generous, such as those proposed (but not yet implemented) in the Care Act 2014. This would increase the number of people eligible for publicly funded care relative to self-funders.
6.2. Such measures would incur an additional cost to the public purse, so would likely need to be accompanied by a revenue raising mechanism or commitment to additional funding.
6.3. Under the current system, self-funders typically pay more for their care; if there is no change in the rates paid, and a significant number of self-funders become eligible for public funding, then providers could see a sudden drop in their income, particularly in those areas where there are a high number of self-funders.
6.5. The following considers some of the most common proposals for reforming adult social care funding.
How does it work?
It is clear?
Raising capital limits
Adjusts the parameters of the current means test – the upper and/or lower capital limits.
No – raising the capital limits would cost more, as more people would be eligible for public funding.
Not for anyone with assets above the upper limit, who still bear risk for the cost of their care. Only once they have depleted their assets to the level of the upper limit will they become eligible for public funding.
Protects the same level of assets (the lower limit) for everyone. The risk remains that this could encourage people to 'spend down' in order to meet the eligibility threshold for public funding.
Even though this is the current system of means-testing, it is complex and generally poorly understood.
Capping care costs
People pay for their care up to a defined lifetime cap, then public funding takes over. This could be coupled with a corresponding floor, below which assets are exempt.
No – introducing a cap would require more public funding (dependent on level it is set at) and would require monitoring of costs and care needs.
Pools the risk of catastrophic care costs, but only among those exceeding the cap.
Intended to protect against catastrophic care costs, but the impact would depend on the level of the cap. A low cap would protect more people, but at greater cost to the public purse. A higher cap may benefit only wealthy individuals.
Lifetime cap is complex and difficult to explain – especially when paired with a floor.
Funds collected from taxation are allocated (or ring-fenced) specifically for social care.
Yes – over both the short and longer term. Could involve ring-fencing a proportion of a specific tax or increasing taxes and allocating this to social care. Would need to be flexible and regularly adjusted if it were to adapt to changing levels of need.
Costs and risks of catastrophic costs would be spread across society, similar to current arrangements for health costs via the NHS.
Fairness and burden would be determined by the detail of how this would operate in practice.
General taxation to pay for public services is well understood.
Inheritance tax increase
Inheritance tax would be increased with a proportion allocated to social care.
Potential to raise revenue, but the amount of tax collected would be dependent on the property market, and so would be difficult to forecast. To keep pace with demand, the increase would likely need to be substantial.
As this is a national tax, it does involve an element of risk pooling. However, given the potentially low levels of revenue and risk of volatility, this would have only limited ability to protect from catastrophic costs.
Unlikely to be perceived as fair, especially where it involves housing assets. While inheritance tax targets those with asset wealth, it carries the risk of being avoidable via tax planning.
As this involves adjusting an existing tax, it is likely to be well understood.
Local taxation increase
Most likely via increasing council tax or precepts.
Additional revenues raised locally, allowing funding to be allocated according to local need. Unlikely to raise sufficient revenues to keep pace with growing demand.
Dependent on mechanism of distribution. Revenues raised unlikely to be sufficient to adequately protect against catastrophic costs.
Local property taxes depend on regional wealth, so could exacerbate inequalities.
Likely to be well understood as operates in same way as existing local taxation.
National Insurance (NI) extension
Extend NI to include contributions from those over state pension age.
Yes – over both the short and longer term, but unlikely to be sufficient to keep pace with growing demand.
Risk is pooled by redistributing costs across society as NI is a national tax. Revenues raised unlikely to be sufficient to adequately protect against catastrophic costs.
NI is levied on income, so risks those with the highest levels of wealth being less likely to pay. Majority of burden would remain on working-age earners.
Easily understood as operates in same way as existing NI contributions.
Mandatory social insurance
Individuals pay into insurance fund ring-fenced for social care, likely by automatic deduction from earnings/pensions.
Yes – in both long and short term. Revenues raised would depend on the level and extent of requirement to contribute. Establishing and administering the system would involve some cost.
Pools risk across society if contributions are made by majority of the population. Has the potential to adequately protect against catastrophic costs.
Generally perceived as fair if contributions set proportionate to income, but potential for those with high wealth and low income to contribute less. Some proposals involve contributions from only those over 40.
No precedent in the UK, so may not be as well understood as in other countries. Highly transparent system, as individuals aware of how much they contribute.
Voluntary insurance (pooled fund)
Contributions are automatically deducted from wages and collated into a pooled fund. Individuals have the choice to opt out of the scheme.
Would enable revenue to be raised in short term as current earners would help fund care for the elderly population, but would take time to raise funds to meet demand. Sustainability would depend on the extent to which people opt out.
Pools risk but only for those who remain opted in. Risk that the system would be unsustainable if too many opted out.
Alongside other direct deductions from earnings, such as auto-enrolment pensions, there is a risk that contributions become too great a burden, potentially encouraging opt out from both. Also risks becoming unsustainable if those on high incomes opt out and find alternative means of funding their care. Unclear what, if any, protection would be in place for those who do not contribute – and the impact this may have on opt out rates.
Potential for comparison to pension scheme. Unlike the pension scheme this runs the risk of seeing no return at all, should there be no need for care.
Voluntary pension scheme (individual fund)
Contributions automatically deducted from earnings and held in an individual fund. Individuals would have the option to opt out. Like auto-enrolment workplace pensions, but unclear whether fund could be ring-fenced for social care.
No immediate revenue raised. Long-term sustainability depends on how much people can save before the need for social care arises. Value of individual funds would be subject to market changes.
No, risk remains with the individual. Unlikely that most individual funds would be sufficient to bear the brunt of catastrophic costs.
Alongside other direct deductions from earnings, such as auto-enrolment pensions, there is a risk that contributions become too great a burden, potentially encouraging opt out from both. Value of individual fund is proportionate to earnings, so likely to be perceived as unfair. Unclear what, if any, protection would be in place for those who do not contribute.
Modelled on existing pension schemes, so likely to be some understanding, but would depend on detail of operation.
7.1. There is a critical need to improve the long-term financial sustainability of the social care system. This can be achieved either by adjusting levels of funding or adjusting service expectations. This is a political and economic choice – but if neither option is taken, an unsustainable position will result. If there is to be no reduction in services, then sustainability requires enough headroom for investment in preventative measures, on a secure enough basis to facilitate long-term planning.
7.2. Although a separate policy matter, it is worth noting the importance of changes to local government financing arrangements. The movement towards incentivising local revenue raising via property taxes ignores the issue of relative need. Unless this is adjusted adequately, the overall sustainability of social care could be fatally undermined.
7.3. After decades of failing to reform adult social care, the experience of COVID-19 should act as a catalyst for change. The reform of social care funding should be strategically informed, financially sustainable, equitable and underpinned by a clear understanding of the challenges of funding social care.
7.4. While we make no recommendations on a given level of spending, nor a specific system for organising the split between state/individual contributions, we propose the following five-point plan for the development of a sustainable system:
This is not intended to be exhaustive, but rather illustrates some of the milestones along the road to reform.
 MHCLG, COVID-19 funding for local government in 2021 to 2022, March 2021.
 MHCLG, Local authority CoviD-19 financial impact monitoring information Round 9, March 2021.
 National Audit Office, Local government finance in the pandemic, March 2021.
 LGA, ADASS, CPA, Social care provider resilience during COVID-19: guidance to commissioners, March 2020 and LGA/ADASS, Temporary funding for adult social care providers during the COVID-19 crisis, April 2020.
 DHSC, Adult Social Care infection Control Fund, June 2020 and Adult Social Care infection Control Fund: round 2, February 2021.
 ADASS, Coronavirus survey, 2020.
 National Care Association, Covid-19 and your care service impact survey, June 2020.
 CIPFA and Institute for Government, How fit were public services for coronavirus, August 2020 and Performance Tracker 2020, November 2020.
 ADASS, Budget Survey 2020, June 2020 shows adult social care made up around 37% of council budgets in 2016/17, 2017/18 and 2018/19 (excluding schools budgets) up from 34% in 2010/11.
 Figures shown apply to England only. Social care is devolved, so the devolved nations have different means tests in place. For residential care the capital thresholds for residential are as follows: Wales has only an upper limit of £50,000; Scotland has lower limit of £17,500 and upper limit of £28,000. In Northern Ireland, limits are as for England.
 This means an individual does not have to sell their home to pay for care during their lifetime, but receive funding from their local authority, who then recover the cost from the sale of their home (eg after their death). DHSC, Care and support statutory guidance, March 2020.
 DHSC, Care and support statutory guidance, March 2020.
 Again, for non-residential care there are differences across the devolved nations. In Wales non-residential care costs are capped at £90 per week. Scotland provides free personal and nursing care. Northern Ireland provides free domiciliary care.
 Commission on Funding of Care and Support (Dilnot Commission), Fairer Funding for All, July 2011.
 NHS, Continuing Health Care (CHC).
 CIPFA and Institute for Government, Performance Tracker 2019, November 2019.
 Institute for Public Care, Surviving the Pandemic: New challenges for adult social care and the social care market, Prof John Bolton, May 2020.
 Institute of Public Care, What are the opportunities and threats for further savings in adult social care? 2016.
 CIPFA, Planning to deliver good value in demand-led services (social care), November 2020.
 CIPFA and Institute for Government, Performance Tracker 2019, November 2019.
 Office for National Statistics, Population estimates for the UK, England and Wales, Scotland and Northern Ireland: mid-2019, June 2020.
 CIPFA and Public Health England, Evaluating preventative investments in public health in England, May 2019.
 CIPFA and Institute for Government, Performance Tracker 2019, November 2019.
 CIPFA and Institute for Government, Performance Tracker 2019, November 2019.
 House of Commons Library, Social care: care home market – structure, issues, and cross-subsidisation (England), 2018.
 Care Act 2014.
 In January 2001, the then Scottish Executive accepted the proposals for free personal care for the over 65’s and legislated for this in the Community Health and Care (Scotland) Act 2002 which came into force in July 2002.
 Although care would be free at point of use after 2015, there would still be the requirement to pay accommodation costs for residential care where they are able, (including a universal deferred payment system to avoid people having to sell their home to pay for care during their lifetime).