Should free personal care be available in England?

Simon Bottery writing at The King’s Fund: Imagine you live in Cornhill-on-Tweed, Northumberland, and, as you get older, find you can no longer get dressed by yourself. You ask your local council for help in your home but discover that, because you have savings of more than £23,250, you will need to pay for it yourself. Welcome to the English social care system.

Now imagine being in the same situation but living in Coldstream, a mile or so over the border in Scotland. Now when you ask for the same kind of help, you will receive it, following assessment, free of charge. Welcome to the Scottish social care system.

The Barker Commission also backed a version of free personal care in 2014 but failed to gain traction for the idea.
social-care-funding-reform”>Our new report with The Health Foundation suggests that it may be time for England to think again. While the cost of implementing the policy would be high, it is only slightly more expensive than the ‘cap and floor’ social care reform proposed by the Conservatives at the last general election. Yet the difference between the two is significant, marking a ‘fork in the road’ on the way to reform. One route – free personal care – moves us towards Scotland: a social care system that is more like the NHS, free for those who need it. The other – the ‘cap and floor’– retains the English, means-tested system for social care.

The ‘cap-and-floor’ model does have some advantages. Unlike free personal care, it directly tackles the issue of the ‘catastrophic’ costs that some people face by ‘capping’ the lifetime costs you might face (though the Conservatives never stated a figure, we assumed this would be £75,000, similar to the level set, but not implemented, in the 2014 Care Act). And it raises the ‘floor’ – the value of assets you can hold and still qualify for state support – from £23,250 to £100,000. But it also has serious, well, flaws. It is extremely complex and difficult to explain. And the value of your house would be counted towards that £100,000 ‘floor’, even for care in your own home (currently it is only counted if you need to move into a care home). Since even a two-bed bungalow in Cornhill-on-Tweed is worth £100,000, that would almost certainly mean you would still have to pay for that help to get dressed. Welcome (back) to England.

Adopting the Scottish model of free personal care, however, would mean that – subject to an assessment of your needs – you would be entitled to free care in your own home.

Adopting the Scottish model of free personal care, however, would mean that – subject to an assessment of your needs – you would be entitled to free care in your own home. You would still need to pay for so-called ‘mopping and shopping’ services (and living and accommodation costs, should you need to move into a care home) but help with basic tasks like washing and dressing at home would be covered. That’s not just good for you but supporting people to live at home is also the over-riding intention of wider health and care policy. Care is delivered closer to home and – potentially at least – in a way that’s more closely integrated with health services – a key priority in Jeremy Hunt’s (and The King’s Fund’s) list of priorities for social care reform and NHS strategy.

CareFree personal care is popular in Scotland and it has been argued it may reduce the overall per-head cost of social care by ensuring that more people access care at home rather than a more expensive care home. In large-scale discussions we held for our report in England, the idea was preferred to the current system (which, someone observed, is ‘obviously crap’). Importantly – and unlike the cap-and-floor model – it was easy to explain to people.

Free personal care is popular in Scotland and it has been argued it may reduce the overall per-head cost of social care by ensuring that more people access care at home rather than a more expensive care home.

Why then has it gone off the agenda in England in recent years? A key concern has been the money. In 1999, the Sutherland Commission split over the idea, with two commissioners dissenting from the recommendation for free personal care because of worries about the cost.

Even when Gordon Brown – somewhat at odds with his own party – introduced legislation in 2010, it was met with scepticism because no source of funding had been identified. And there remains a concern that removing the means test effectively shifts at least some of the cost from the private pocket to the public purse.

Ironically, though, it is the cost of the alternatives to free personal care – and in particular the cap-and-floor model – that may help rehabilitate the idea. Ploughing more money into the current, broken social care system seems like poor value. Simply keeping pace with rising demand will involve spending an extra £6 billion by 2030/31. ‘Resetting’ the system to the level of access in 2009/10 would cost £15 billion. Proper reform does not come cheap either. Even with its flaws, the Conservatives cap-and-floor model would still cost an additional £12 billion by 2030/31. For slightly more investment (£14 billion), we could have free personal care.

The decision about a model of reform – whether free personal care, the cap-and-floor model or any other – should be based on which of the many problems with social care we most want to solve. If we believe the most pressing problems are an inadequate public offer and an overly complex system with high administration costs and barriers to integration with health, then free personal care – or some variant of it – may be an idea whose time has finally arrived.

Source: Simon Bottery at The King’s Fund

Unwell, unsafe, and unfed – 4,000 people needing care reveal a shocking picture of neglect in our care system

 A survey by the Care and Support Alliance (CSA) (*), of nearly 4,000 people who need care or look after someone who does reveals the damning reality of a care system that is visibly failing and unfit for purpose. Those relying on care revealed their experiences of poor care – in the worst cases amounting to neglect – at the hands of a care system that is meant to provide a safety net for them but which often lacks the resources to do so.

The survey revealed, because of a lack of care:

  • 1 in 5 felt unsafe moving around their own home, and 4 in 10 can’t leave it.
  • 1 in 5 said they’ve gone without meals.
  • 1 in 4 said they’ve needed hospital treatment and 1 in 8 told us they’ve been delayed leaving hospital because of not being able to get the care they need.
  • Over a quarter have been unable to maintain basics like washing, dressing, visiting the toilet.
  • Over 1 in 7 (16%) have had their care packages reduced, even though their needs have increased or stayed the same.
  • Over 1 in 5 have not been able to work.

The Alliance is calling on people to add their signature to an open letter to Jeremy Hunt, Secretary of State for Health and Social Care, highlighting the urgent need for him to act now and in the upcoming Green Paper to fix the care crisis

Care and Support Alliance

Currently 1.2 million older and disabled people are unable to get the care they need, almost double the number since 2010(1). And despite more adults needing care, the number of receiving it has fallen by at least a quarter between 2009/10 and 2013/14 alone (2). A £2.5 billion funding gap is estimated by 2019/20 (3).

This most recent CSA survey highlights the dangers of not having enough care; the unnecessary pressure being placed on the NHS and how family and friends who step in to try to fill the gap are being pushed to breaking point.

The NHS picking up the cost of care creates unnecessary inefficiency – a hospital bed costs £2,800 a week compared to £600 for personal care in a care home and less still for care at home (4).

In the CSA report out today ‘Voices from the social care crisis’, people shared their experiences:

Lorraine Hammond, 47, from Lincoln, tried for years to get her mum good help, but carers at home and in two care homes failed to give her the care she needed. She described common problems, such as “The carers hadn’t been feeding her lunch, they had just been leaving cold soup by her bed.”

Keith Bright, 58, from Norwich said “We’re worried about our situation in the long-term, and can’t see how it can go on like this. We just can’t do this anymore, we’ve spend over £28,000 in five years on social care, and we don’t know what’s going to happen in the future.”

Caroline Abrahams, Charity Director at Age UK and co-Chair of the Care and Support Alliance, said:

“The experiences of thousands of people in this survey are damning evidence that that our adult social care system is broken and unfit for purpose. It is especially worrying to have heard stories from people whose care has been cut, even though their needs have either stayed the same or got worse. And the reality is that care cuts aren’t saving the Government money, the NHS is picking up the bill as people are pushed into ill health and crisis because of a lack of basic help.

“The Government must provide funding now, as well as focus on future reforms, as essential steps towards getting our care system back on track.”

Mark Lever, Chief Executive of the National Autistic Society and co-Chair of the Care and Support Alliance, said:

“Inadequate care is now a common problem across the country and it is those who need care and their families who are paying the highest price. The stories of frustration and heartache we heard are all too common.

“Regardless of someone’s condition or age people should be getting care so they can live safely and with dignity. The Government must ensure the upcoming Green Paper proposes effective ways of meeting the country’s social care needs and urgent funding is also required so stop the widespread poor care and neglect our survey has uncovered.”

Respondents to the survey said:“I haven’t been washed for over two months. My bedroom floor has only been vacuumed once in three years. My sheets have not been changed in about six months, and my pyjamas haven’t been changed this year. My care workers don’t have time for cleaning, washing or changing me.”

“I feel 100% let down and not heard”

“When I was caring for my mother at home getting respite care was very hard – In fact for a long time I didn’t know I was entitled. It’s a lottery as to whether social services give you the information you need about what you are entitled to as a carer.”

“I’ve become a burden to my family, lost many friends and just can’t be the husband and partner, I would like to be. It’s not just me that suffers, but all the family.”

End notes

The Care and Support Alliance (CSA) – is a coalition of more than 80 of the country’s leading charities (including Age UK, MS Society, Independent Age, National Autistic Society and Alzheimer’s Society, Scope) – who are calling for a properly funded care system.

About social care

Social care is an essential life support system that people rely on for everyday tasks like washing, dressing, eating and managing in the home. It also enables those who can to work, volunteer and take part in society. It helps people get out and about and is meant to support them not just to live but to have a life. Without social care, many people would be lonely and isolated, as well as at risk of crisis.

*About the survey: CSA ran an online survey 24th January 18 to the 9th March 18. The survey was shared via CSA members and was completed by 3,915 self-selecting people who identified as having experience of adult social care in England.


  1. Age UK, February 2017, Briefing: Health and Care of Older People in England 2017
  2. The Health Foundation ‘Briefing: The social care funding gap,’ 2017
  4. Laing Buisson Care of older people UK market report 28th edition, May 2017

Key findings from the report

People told us because of not getting the care they need:

  • Over 4 in 10 said their health deteriorated
  • 1 in 4 needed hospital treatment – 1 in 8 had to stay longer in hospital and 1 in 6 missed medical appointments)
  • 1 in 5 have gone without meals
  • 1 in 5 said they have been unable to move around their own home safely
  • Over a third said they had not able to leave the house because of a lack of social care
  • Over a quarter have not been able to maintain basics like washing, dressing, visiting the toilet
  • Over half can’t do the things that are important to them
  • 4 in 10 feel lonely or isolated
  • Nearly half have had to rely on family and friends more
  • Nearly 1 in 10 were unable to care for dependents, such as children or parents
  • 1 in 10 hadn’t been able to take a break from caring for someone
  • Over 1 in 7 people (16%) have had their care packages reduced even though their needs have increased or stayed the same
  • Over 1 in 5 have not been able to work.

Source: The Care and Support Alliance