Research by LSE’s Care Policy and Evaluation Centre has informed policy decisions on the eligibility, funding, delivery, and outcomes of adult social care in England.
What was the problem?
Two million adults require social care in England. They are supported by 6.5 million family members or friends and 1.5 million care professionals. To keep pace with demographic and other pressures, public expenditure on social services in England for older people would need to rise from £8.4 billion in 2018 to £16.5 billion in 2038, and for younger adults from £9.6 billion to £18.1 billion (at 2018 prices).
The long-term provision of social care – and how to fund it – is one of the most intractable areas for domestic policymaking, which has raised numerous, interrelated questions around eligibility, demand, funding, and staffing, even before the COVID-19 pandemic. When the pandemic hit in 2020, it rapidly became apparent that long-term care facilities were particularly vulnerable. Globally this has created huge pressures on social care systems, and brought into sharp focus the need for long-term solutions.
What did we do?
LSE’s Care Policy and Evaluation Centre (CPEC) runs a multifaceted programme of research addressing policy questions in social care.
Between 2012 and 2014, Dr José Luis Fernández led a research programme to support the Department of Health and Social Care (DHSC) in developing new eligibility criteria for individuals to receive social care in England. It identified a lack of clarity in the existing criteria, which were based on loosely defined categories of need, leading to significant variability in assessments by care managers and local differences in implementation. This resulted in significant inequalities in access to social care. CPEC studies analysed case study data to evaluate possible alternative eligibility regulations. The research suggested that more transparent, wellbeing-focused criteria for social care could be introduced without significantly increasing public expenditure.
Raphael Wittenberg leads CPEC’s research programme on long-term projections of social care demand and expenditure, which models the extent of spending growth required. These micro- and macro-models inform the UK government’s proposals for funding reform.
To examine public attitudes on how to fund this growing need for social care, two House of Commons select committees jointly commissioned a Citizens’ Assembly, where members of the public were invited to deliberate on the issues. Professor Martin Knapp was the project’s expert lead for social care funding and provided impartial evidence to participants. The Citizens’ Assembly recommended a publicly funded social care system free at the point of use. Knapp and Wittenberg also led a national survey of public attitudes to paying for social care. The majority of respondents thought costs should be shared between the state and the service user, with relatively low individual contributions of around 20 to 50 per cent.
In work on supporting unpaid carers, CPEC reviewed the evidence on the economics of caring to inform the DHSC’s review of its Carers Action Plan. Its recommendations stressed supporting unpaid carers through formal care services and ensuring flexible working arrangements to improve employment outcomes. Modelling of unpaid care found that keeping pace with future demand from older people would require 3.1 million more carers by 2035. Fernández also found that, although the Care Act 2014 gave unpaid carers new rights to needs assessments and entitlements, support for them continued to fall after its implementation.
In the first half of 2020, Adelina Comas-Herrera established the Long-Term Care Responses to COVID-19 project (LTCcovid.org) to share emerging international evidence on the impact of the pandemic on social care, with contributions from CPEC and international experts. Its report on COVID-19-related mortality indicated, for the first time, that care home residents accounted for about half of all COVID-19 deaths. This work also highlighted early evidence of asymptomatic transmission in care homes and international examples of guidance to address this problem. Two subsequent widely quoted technical reports were produced for the World Health Organization.
Fernández led research for the London Association of Directors of Adult Social Services (ADASS) to support the city’s COVID-19 response in the social care sector. Daily data collected from more than 1,300 care homes and over 1,100 home care providers were used to identify provider-level COVID-19 risk factors and impacts on the care workforce and financial sustainability. This enabled CPEC to develop a pan-London projections model for likely capacity in the social care sector.
CPEC research has helped to shape policy decisions on the eligibility, funding, delivery, outcomes, and cost-effectiveness of adult social care, particularly in England. It has also helped to shape local, national, and international responses to the COVID-19 pandemic.
In 2014, CPEC’s research informed new minimum national eligibility regulations for social care, with Fernández invited to join DHSC’s taskforce responsible for defining these and providing guidance on the legislation. These new thresholds enable English local authorities to assess individuals’ eligibility for statutory support more fairly and transparently.
CPEC’s work on long-term care projections fed into the Office of Budgetary Responsibility’s July 2018 fiscal sustainability report. The analysis for DHSC is informing policy discussions linked to funding reform, and CPEC models underpin work on future costs for social care by DHSC and across government. CPEC members also regularly provide expert evidence to parliamentary select committees. Findings from the Citizens’ Assembly on social care were heavily quoted by the joint report from two House of Commons select committees (2018), influencing their recommendation that personal care support should be delivered free to everyone who needs it.
Research on the economics of caring is also informing DHSC’s review of its carers’ strategy. CPEC findings were discussed with several government departments, and LSE researchers were asked by DHSC to conduct further modelling of unpaid care demand and supply. As partners in the National Institute for Health and Care Excellence (NICE) Collaborating Centre on Social Care, CPEC’s cost-effectiveness analysis fed into NICE guidance on home care, older people with multiple needs, transition from hospital to community settings, and transition for children to adult services. These guidelines inform the work of local authorities across England.
The “Long-Term Care Responses to COVID-19" project led by Comas-Herrera shared evidence-based insights with policymakers and practitioners at local, national, and international levels. She provided evidence to the Health and Social Care Select Committee on the management of COVID-19 and briefed the Minister of State for Care on care home visits. Comas-Herrera is also a member of the Cabinet Office’s Expert Advisory Group for the International Best Practice Advisory Group and has provided advice, for example, on testing policies for care homes.
CPEC’s partnership with London’s ADASS meant their daily reports on COVID-19 risks informed local operational decisions across London, for instance on the distribution of PPE, support with staffing of care homes, and the targeting of testing kits. CPEC analysis also helped target the distribution of infection control grants during the pandemic. The London analysis was shared with DHSC and local authorities across England and subsequently CPEC was invited to lead the analytical stream of the new Adult Social Care Market Insight Board, which promotes evidence-based policy across the London care sector.