Self-funders and Social Care: from bystanders to core participants?

By Melanie Henwood who is an independent research consultant, and an Associate of the Health Services Management Centre, University of Birmingham.

As the dust settles on the NHS Ten Year Plan, social care continues to await the Green Paper that will start to address the limitations in its funding and delivery. The lack of apparent coherence in failing to publish the two plans simultaneously and to demonstrate integration of vision has been the focus of some criticism. The crisis of funding in adult social care has two main (and inter-related) dimensions.  On the one hand is the inadequacy of the size of the  overall pot of public money dedicated to care, and on the other is the division of financial responsibilities between the public purse and people who pay for their own care and support (‘self-funders’). The long-term funding of social care has been a major policy challenge for successive governments over many years, and whether the much delayed social care Green Paper will offer a lasting and secure settlement will be the focus of much debate.

For local councils (who arrange publicly-funded care), how social care is funded and whether there is to be a new social contract between individuals and the state are major questions which impact on their understanding and capacity to shape the care market.  Many of the  commitments in the Care Act 2014 around delivering more person-centred support and ensuring that self-funders are treated as important participants in the care process have been frustrated by the delayed implementation of the Act.  However, understanding the nature of the self-funder population is vital as this has a major impact on local care markets – potentially ensuring the viability of providers, but also risking major destabilisation if self-funders don’t continue to subsidise publicly-funded care places.

An interim report informed by  Department Of Health and Social Care-funded research projects brings together the latest quantitative data and analysis of estimated numbers of self-funders, together with reflections from a review of literature examining how local authorities are meeting their responsibilities to self-funders. 

One of the key characteristics of self-funders is their relative invisibility compared to people who use publicly-funded care services. Some of them may be known to the local authority, but many do not approach the local authority and remain invisible.  Our new analysis of recent data suggests a much higher proportion of people are self-funding than previously estimated.  Information has been derived from the UK Household Longitudinal Survey (UKHLS) showing 350,000 self-funders (of care home places and home care) in England. The figures also suggest that approximately one and a half times as many older people are paying for care at home as are paying for residential care.

Alongside the quantitative data, our review explored the literature against a map of hypotheses about the way the Care Act should operate (its ‘theory of change). Much of this literature highlights constraints on local authorities’ capacity to support people to make effective care choices. It explores the multiple challenges and obstacles to the transformational approach set out in the Care Act, and the inherent contradictions and tensions in the role and responsibilities of local authorities in implementing the Act.

A key test for the implementation of the Care Act is whether future evaluation will indicate that the experience of self-funders is qualitatively different and better than before the Act.  How this can be judged, and the specific questions that need to be asked, should be significantly informed by this review and its consideration of the theory of change implicit in the Care Act. From a research perspective, locating the situation of self-funders within the wider context of the logic and limitations of the care market has advanced our understanding of self-funders and their experience. Of wider relevance, it is obvious that the presence of self-funders shapes and re-shapes the social care market in ways which have a profound impact. They can no longer be seen as incidental to the operation of adult social care, but as integral to it.

This blog is based on independent research commissioned and funded by the NIHR Policy Research Programme. It draws on research undertaken for two projects: PR-R14-1215- 21004 Shifting-Shapes: How can local care markets support quality and choice for all? and PR-ST-1116-10001 Shaping Personalised Outcomes - how is the Care Act promoting the personalisation of care and support? The views expressed in this blog are those of the author and not necessarily those of the NHS, the NIHR, the Department of Health and Social Care, or its arm’s length bodies or other government departments.