Section 3 – Public attitudes to social care funding reform

This section reflects on the findings from research into public attitudes that ran alongside our joint Health Foundation and King’s Fund analysis of funding options for social care. The research aimed to explore the public’s knowledge and experience of social care in general, but also how people responded to the options we put forward, and what values and beliefs were brought into play as they reacted.

The section draws on two sources of primary research: qualitative work with the public and questions asked in the most recent British Social Attitudes Survey.

Qualitative element

Ipsos MORI was commissioned to conduct the qualitative element. The study used reconvened deliberative workshops and in-depth interviews to explore experiences and priorities among the public and users of social care. We wanted to explore current levels of understanding and reactions to the current funding model before testing possible future funding options. Deliberative events are a method well suited to moving people through a process of information-giving, allowing the time and space for participants to digest and reflect on stimulus materials. This provides an opportunity to reflect on complex issues like social care funding, though efforts should be made to draw conclusions for the wider population who have not been through such a process.

Two day-long workshops were held in three different locations in England: London, Leeds and King’s Lynn between January and February 2018, attended by 116 people. The workshops in each location were held three weeks apart, and the same groups attended on both days. The groups were mixed in terms of age, gender, social background and ethnicity.

Quantitative element

We also commissioned four questions on social care in the 2017 British Social Attitudes Survey. Since 1983, NatCen’s Social Research British Social Attitudes Survey has asked members of the public about their views and feelings on a range of issues and policy areas, including the NHS and social care.

The latest survey was carried out between July and October 2017 and asked a nationally representative sample of 3,004 adults in England, Scotland and Wales their views on social care funding. In the analysis that follows, the differences highlighted are statistically significant at the 95% level unless otherwise stated.

What we learnt from this work

1. The public has limited knowledge of what social care is 

It is clear from the 2018 deliberative events that public understanding of social care remains limited, although there are signs that awareness has increased since 2008. Participants in the deliberative events were able to categorise in very general terms what sorts of services would be provided by social care and what were more likely to be health, but there were still many grey areas. People were much less clear on how to access social care and how services are managed. Many participants assumed their GP was the entry point to the system. Local authorities were rarely mentioned spontaneously as having a role in providing social care.

It might be expected that direct experience of social care would lead to greater knowledge. To some extent this was the case. However, even those people who had experience of social care, either personally or through friends and family, were not confident about their understanding of the wider system. Rather, the experiences cited were very individual accounts of seeking care and support. People described how hard it was to navigate the system and the frustration faced in getting through the bureaucracy involved in accessing care.

The biggest thing I found is no one seems to know where to get help. Not knowing where to go, or who to get advice from, to get everything started. There doesn’t seem to be any one place.

Leeds, Workshop 2

What does seem to have filtered through to public awareness is negative media coverage of social care services. People mentioned reports of abuse and neglect in care homes, which were often attributed to perceptions that the workforce were both low-skilled and low-paid. Participants also referred to media stories about the underfunding of the social care system.

A system under stress. Money isn’t being made available by the government, so less people have got to do more work.

King’s Lynn, Workshop 1

You only hear negative things, like people abused in care.

Leeds, Workshop 2

2. The public has even less knowledge of how social care is funded.

While there was some, albeit limited, understanding of what social care is, there was very low awareness of how social care is currently funded. Most people, particularly those who had little or no personal experience of social care, thought it was funded in a similar way to the NHS (ie through tax revenues, and free at the point of need) or that they would be able to draw on an entitlement based on NI contributions. They also assume that state-funded care would be provided to most people, with government paying for at least some, or even all, of the care people need.

Personal experience of accessing social care, either directly or on behalf of a family member, brings more knowledge of funding, but within limits. In the deliberative events, people with experience were well informed in relation to their own circumstances, but were often unsure of, for example, what the financial threshold for eligibility was. Although some had experience of their assets, including housing, being used for payment, people’s accounts were often more dominated by the pressures of arranging care, often at moments of crisis, and relief when care was put in place. They were less able to provide an overview of how the system is funded.

The British Social Attitudes Survey asked people who they think currently pays for social care (defined as needing regular help looking after oneself because of illness, disability or old age. This can include help with getting washed, dressed, preparing meals, or care in a nursing home.) The findings reflect what people told us in the deliberative events: there is no clear understanding of how social care is currently funded. A third (34%) say the government currently pays for care, while 12% say the individual pays. Just over half (51%) gave answers that reflect a belief that costs are shared between the government and the individual.

Figure 2: Perceptions of who currently pays for care, from the British Social Attitudes Survey

Source: National Centre for Social Research’s British Social Attitudes survey, 2017

As noted, when reviewing quantitative survey questions asking about social care, we should take into account the lack of understanding in this area. Quantitative views held about the current system need to be interpreted through our qualitative understanding of public attitudes.

Box 2: Analysis: overall perceptions of social care

It is easy to see why efforts to reform social care have repeatedly hit a stumbling block when it comes to communicating with the public. For people to show support for a solution to a problem, they first need to see it as a problem, and at the moment this is happening only in a limited way.

Although some people have direct or indirect experience of arranging social care, we found that their experience does not give them insight into the system as a whole. Furthermore, the realities of navigating a complex and bureaucratic structure at a time of personal crisis are overwhelming.

That being said, the results of the British Social Attitudes survey in 2017 showed the lowest level of satisfaction with social care (23%) since the question was first asked in 2005. The deliberative events demonstrated that while knowledge of social care was low, there was an emerging sense that there are mounting problems with social care around funding, workforce and the level of care provided.

3. When informed, people think the current funding model needs to change

The reaction to the current funding model was unanimously negative. People were often shocked when the details of the means test were explained to them. The financial threshold was seen as very low and many people were unfamiliar with the idea that housing assets might be included in the assessment. The suggestion that housing would be taken into account provoked particularly strong negative emotions.

When people were taken through the system as it exists today, there was sometimes a sense of anger as people realised their assumptions that their care would be paid for by lifelong tax and NI contributions were clearly wrong.

There was a strong feeling that what is currently in place is not fit for purpose and needs to change. The reaction led many to feel concerned for how they or their loved ones would be provided for in later life.

Exposure to details of the current model led many to question why so little was understood about social care, why existing information on the system is hard to access and, where it does exist, why it is confusing and unclear.

Box 3: Analysis: perceptions of the problem and potential solutions

The deliberative events demonstrated that when people are given further information about social care, they recognise there is a significant problem and believe the current funding system is not fit for purpose.

However, currently a large proportion of the public assume social care will be free at the point of need, paid for by government through taxes and NI. It is unsurprising, then, that new proposals that may involve increased contributions from individuals are seen in a negative light, even if objectively they are more generous than the actual current model.

This is important and in part explains the reaction to the proposals outlined in the Conservative Party manifesto of 2017. While the manifesto pledges were in fact more generous than the current system, it could be argued they would not be seen as such if people think social care is currently free or at least heavily subsidised.

Any potential solution has to be seen as an improvement, but this will only be possible if people understand what is already in place, rather than thinking that the system will be free at the point of need or at least subsidised more significantly than it currently is.

This raises a significant question about how wider knowledge and awareness can be raised and, perhaps more importantly, who should be leading any wider public engagement. It was clear from the deliberative events that trust in government was at a low ebb, not least on this issue. At the same time, participants struggled to identify who they would trust to lead engagement on social care.

4. Underlying public beliefs about the role of government and fairness need to be recognised

Two areas of people’s underlying values and beliefs strongly shaped attitudes towards alternative funding models, namely beliefs about the role of government and how the concept of fairness was understood.

Views on the role of government as a vehicle for resolving the failures of the current system revealed a paradox. On the one hand, there was agreement that the system was not working and government needed to take a leading role in fixing it. On the other hand, some people were not convinced that government was capable of providing a lasting solution to the problem and did not trust them to do so.

As can be seen from Figure 3, most people favoured the idea of the state having most responsibility for funding social care, placing themselves on the ‘state pays’ and ‘state pays with some contribution’ end of a spectrum that has individual responsibility at the other end.

The findings of the deliberative work reflect the findings of the British Social Attitudes Survey. The state paying for everything was also favoured by a significant proportion of respondents to the British Social Attitudes Survey: 41% opted for ‘the government, paid for by taxes’ and 2% chose ‘the individual’ (Figure 4).

Figure 3: Perceptions on the balance of responsibility, from the IpsosMORI workshops

Figure 4: Perceptions of who respondents think should pay for social care, from the British Social Attitudes Survey

Source: National Centre for Social Research’s British Social Attitudes survey, 2017

Most people (55%) favoured options where responsibility was shared, namely ‘means tested’ (30%) and ‘means tested and capped’ (25%).

But these views about the important role of government in both fixing and funding social care often coexisted with doubt about government’s capacity and trustworthiness to do so. People were concerned that any funding solution needed to endure for decades to come and should be protected from the pursuit of short-term political goals.

Throughout the deliberative events, people often spoke about setting up an independent body, either in relation to deciding on the right funding levels or to actually administer social care spending. Allied to this was a preference for a dedicated tax, which emerged repeatedly, even before being discussed as one of the options (see below). Such a tax was seen as transparent and would allow people to see where their money was going. There was also a sense that a dedicated tax would stop the money being diverted to areas of government spending that were seen by some as less important, for example foreign aid.

Housing wealth

A major factor that powerfully shaped attitudes was people’s attachment to their homes as a dominant dimension of fairness. This included the idea of home ownership and the hard, lifelong work that homes represented for most people, so that even those who did not own a home wanted to protect those who did. People felt that it was very unfair for government to take into account the value of their homes under the existing model. Even after being exposed to the scale of the future funding pressures, most were still hostile to the idea.

Just forget about touching people’s houses. That should be a principle. Just get rid of that rule. Take peoples’ houses out of it. You work for that. It’s for generations to come. It’s yours. You can find other ways of raising money, and leave people’s houses out of it.

Leeds, Workshop 2

Behind this view was a conviction that people had worked hard for their homes and had the right to dispose of them as they saw fit. Moreover, there was a view that home ownership had been actively encouraged by government and that any move to include houses in the assessment of assets went against what people had been advised to do.

We’ve all had to sacrifice something to get something. I sacrificed a lot to get a house, so why should I now, as an older woman, lose my home?

Leeds, Workshop 2

There was also a question mark over how regional differences in house prices might be taken into account, as can be seen below in reactions to the cap and floor model.

There were mixed views on whether or not wealthier people should be responsible for paying for their own care. There was broad agreement that ‘very wealthy’ individuals should be, but less consensus on who these people are and how a means-tested system should be set up.

While the use of people’s housing assets dominated concepts of fairness, a few other dimensions were explored. Views included the idea of a basic package for all (with the freedom to top up for those with the means), to accepting that means testing is inevitable, but with much more generous thresholds than at present.

On the question of fairness between generations, most people understood that social care reform might disproportionately benefit older generations. However, they saw this as a consequence of being fair to older generations in a different way – recognising they had already ‘paid in’ to the system – and because they wanted to protect housing assets. These two latter types of fairness overrode the notion of fairness to younger generations, partly because they were seen to have more time to adjust to the idea and partly because ‘we have to start somewhere’.

Although people recognised that younger generations faced financial challenges, this was balanced by a strong sense that it is important to be fair to older generations.

How else can you do it? Older people will have paid for somebody else? It’s like with your children. It’s rolling over. They work, contribute, pay taxes. It’s how we evolve as a society. My children will pay for other people.

London, Workshop 2

That’s how society works. For the greater good and all. When young people get older, they are going to be in the same position as the older people. It just goes around and around.

London, Workshop 2

We have done our share. Now it’s down to the next generation.

Kings Lynn, Workshop 2

Box 4: Analysis: perceptions around funding

The strength of people’s attachment to their homes seems to trump any attempts to solve social care problems by an appeal to intergenerational fairness by including housing wealth – wealth that is largely held by older generations. It was striking that the public, in these deliberative events, did not buy arguments that a solution that spared the use of housing assets among the current older generation would be unfair to the younger generations. Or if they did, they thought that it was more important to be fair to people who had ’paid in‘ all their lives and worked hard to buy their houses.

However clear the potential intergenerational unfairness may seem to those working in policy circles – for example, the growing disparity in home-owning status between generations – it would seem that solutions that try to mitigate the divide in intergenerational wealth might have limited traction with the public, at least at the moment.

What did seem apparent from this work, even among younger people, was a sense that it was important to be fair to older generations who have paid in all their lives and thought their social care needs would be met through their tax and NI contributions over many years. It is likely that people’s experience of living in families that span generations is a more constructive frame on which to build.

5. Public responses to the alternative funding options

Continuing with the current system

The sample of the public in our deliberative work fairly quickly reached the view that the current system needed to change for the reasons outlined here, including hostility to the use of housing assets to pay for care and unrealistically low thresholds for state help. The perception that the current system failed to deliver quality care was also a concern for some participants, and was seen as another reason it needed to change. These views were influenced by media stories reporting abusive care homes, or personal experiences of friends and relatives receiving care that was perceived as low quality, including short visits from carers.

The current system doesn’t work. It’s going to continue to get worse. The funding is not enough for the level of care that’s needed. I often wonder how seriously the government is thinking properly about this.

Kings Lynn, Workshop 2

Changes to the cap and floor system

People found these changes complicated and difficult to understand, even after considerable discussion of how they might work. They were seen, nevertheless, as an improvement on the current model, offering greater certainty about costs, and a guarantee of some assets to pass on to family. However, it is important to note that while perceived as improvements, they were not viewed positively, and the difficulty in understanding how the changes might work should not be underestimated.

It is confusing. I understand it, but we’ve probably got different interpretations.

Kings Lynn, Workshop 2

I disagree with the fundamentals, but I think if you’re going to have a system with a cap, it does lead to some certainty, compared to where things are at the moment.

London, Workshop 2

As before, many participants were reluctant to consider using housing assets, or suggested alternative ways of calculating the cap based on region. This was because there was concern that this option did not take into account differences in house prices across the country and could more negatively impact some groups of people.

You can’t even get help in your own house without that property being included. If you have an expensive property, you could forever be having to pay for it yourself. You have to sell the house.

Kings Lynn, Workshop 2

I think it should be a percentage rather than an absolute number. If you have a house of a million pounds you’d lose an awful lot of money.

Leeds, Workshop 2

It depends where you live. My friends have sold their house in Leeds to go to Huddersfield and pay it off, because the standard of property in Leeds is higher. It’s not a national system – you’re subject to the variations of the housing market. In Burnley and Bolton it’s £45,000 for an average house.Leeds, Workshop 2

Linked to this, people were also concerned about regional differences in the cost of care. People worried that those living in areas where care was more expensive might reach the cap sooner than in other areas. Again, participants felt that the model should be proportionate to the value of the home, rather than a single capped amount.

We talked about how different regions have different assets. What if the cap was in correlation to where you are living?

London, Workshop 2

I think you’re going to have to do it on a percentage of the value of the property, not the set value of £100,000.

Kings Lynn, Workshop 2

Free personal care

This option was relatively well received, although there was wariness about how much it might cost. People liked it because it did not discriminate against those who had saved, while offering some level of security to everyone. Some also felt it would enable older people to be independent and stay in their own homes for longer. In addition to worries about how much this might cost (and whether it would be at the expense of other areas of government spending), participants were also aware that setting the needs threshold might not be straightforward, and that some people just below the threshold might lose out.

In principle I like it because you don’t discriminate against people who have saved.

London, Workshop 2

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

Leeds, Worksop 2

If everyone qualifies for it, the assessment will be stricter. There will be a grey area of knowing you need it, but they say you don’t because they can only afford a certain amount.

London, Workshop 2

A dedicated social care tax

This option also struck a chord with many participants, and the idea of raising taxes was referred to throughout the workshops. Many people decided early on in the deliberative process that increased taxes would be necessary and some even suggested an approach that had features of a dedicated tax.

A dedicated tax was seen as a way of ensuring that government would be accountable for the money going to social care rather than other areas of government spending. This option was favoured because it fitted in with people’s concerns around fairness and also mitigated the lack of trust in government.

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.

Kings Lynn, Workshop 2

Reducing flexibility of how government spend the money is an advantage.

Leeds, Workshop 2

I like the idea because you are paying straight out your wage and you know that you are covered.

London, Workshop 2

Over the course of the workshops, discussions around taxation frequently focused on the benefits and value of knowing how much and where money was being spent. A key concern for participants was how the money raised through one tax (eg road tax) was being spent to fund other services (eg education). They wanted the new system of social care funding to provide a guarantee that the money raised for social care would be spent on social care. Participants also felt that a dedicated tax would provide greater security that social care provision would be there for people who need it. It was also preferred because it was a solution that did not target housing assets.

If you asked people whether they would pay two extra pence on income tax rather than take away assets later on they would choose the former. But I have no confidence the government will use the money appropriately.

Leeds, Workshop 2

Overall, participants argued that ring-fencing money specifically for social care would also make increasing tax more palatable to the public, if announcement of the new tax was combined with a campaign to raise awareness about the challenges facing social care. The discussion also opened broader questions about whether other areas of government spending should adopt this model.

I think [a dedicated tax] is an opportunity to look at in the NHS.

Kings Lynn, Workshop 2

Nevertheless, others were sceptical that such an approach would be resilient and sustainable, particularly if there was a recession and revenue from taxes fell. There was also a concern that a dedicated tax might not raise the money that is needed to improve social care services.

It says dedicated tax. No money could be spent elsewhere. Does that mean no money could be coming in from elsewhere? What if there were mass unemployment?

Leeds, Workshop 2

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 2

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 2

A joint social care and NHS budget

This was also an appealing option to many people, because they saw the two services as closely linked or overlapping in some instances. There was a sense that this solution might reduce some of the pressures that both sectors face and improve services for patients or care users because it might lead to improved coordination. An example raised was that individuals might receive social care earlier preventing them from needing to go into hospital.

So many beds are taken up by people who need to be taken care of by social care because there’s nowhere else for them to go. If it was overseen by one organisation who looked at the bigger picture, it might help.

London, Workshop 2

I somehow see that social care is part of the NHS. It is part of the nation’s health. Why does it have to be two separate units?

Kings Lynn, Workshop 2

There needs to be better integration between the two. If you’ve got a pensioner who’s in bed in hospital but is well enough to go to a nursing home, if the problem is in-between then that can be worked out.

London, Workshop 2

But there were also those who were worried about this option. People argued that as the NHS was also under financial pressure, there would be tension between the two services and a risk that health would win out over social care.

If it comes down to saving a sick child or an elderly person who might not last another couple of years, where will the money go?

London, Workshop 2

The NHS is a waste of money. I don’t like this model. People are too dependent on the NHS. Mixing the two together, NHS would end up spending the money.

Leeds, Workshop 2

Features of a better system?

At the end of the deliberative events, participants were divided into small groups and tasked with developing their ideal system, based on the key features that were important to them.

Any new system should be built on the following key principles:

  • Standards: good and consistent quality care
  • Transparency: clear information about costs and where funding goes
  • Sustainability: a system built to last over the long term
  • Choice: control over care options
  • Accessibility: easy-to-navigate services
  • Fairness: everyone contributing to social care funding.

On the funding side, most people mentioned a dedicated social care tax because this was perceived as the fairest and most transparent way to raise additional money. Some people added a cap on costs, to protect individuals’ assets. There were many who liked the idea of a basic level of care available to everyone, regardless of their income or assets. But others also warmed to the idea that those who could contribute to their costs should do so, via some sort of means test.

On the management side, a joint budget between health and social care was popular (although additional money was seen to be needed for the NHS, too), as was an independent body to oversee the funding, to guarantee quality and fairness of provision across the country.

Participants also felt strongly that any new funding model should be clearly communicated (the sense of anger generated by not knowing about the current system lingered throughout the workshops). It should be sustainable and last over decades, care provided should be of good quality everywhere, and it should be transparent and simple to access.

Box 5: Analysis: perceptions of costs

It is important to remember that throughout the deliberative events and in the surveys, the public were not confronted with any calculations of the potential global costs of the various options.

FPC and a joint social care and NHS budget were attractive options to people. But our research also sounds some alarm bells about the implications of going down this route: a minority of people are far from convinced that the NHS is as waste-free and well managed as it could be, and the lack of a clear public service identity for social care made people worry that older people’s care would lose out in the battle for resources.

However, when it comes to a means-tested option, it was instructive to see during the deliberative events how difficult people found it to understand the complexities of the idea of a cap and floor for care. Even after ample time for discussion, this approach was deeply confusing, and only reluctantly seen as preferable to the existing arrangements. Even then, only a minority of people were willing to concede that there might be an acceptable trade-off between allowing their housing assets to be used and a system that would potentially protect more people with a basic level of care.

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