Building public support for social care reform: what can England learn from other countries?

Too often, proposals for reform have been rapidly drawn into a toxic political spiral which have left politicians burnt and relegated to the bottom of the agenda again. Labour’s proposals to raise revenue from inheritance tax ahead of the 2010 election, for example, were quickly branded a ‘death tax’ by the Conservatives and widely blamed for Labour losing the election. Similarly in 2017, the Conservative manifesto pledge to change the social care means test was branded a ‘dementia tax’ by the Liberal Democrats and contributed to the loss of a large majority. The passing of the Care Act in 2014 represented cross-party agreement on change but the political will to follow through with funding to make it a reality ebbed and much of what was planned was quietly dropped.

And so, here we are in early 2022, with yet another reform white paper behind us, what are the chances that progress will be made this time? We have examined the social care systems in Japan and Germany – two countries that successfully brought about comprehensive reform over 20 years ago – and looked at what we can learn about the ingredients that are needed to effect change.

Public support is crucial

In both countries, building public support for reform was the crucial starting-point in their journeys. A groundswell of discontent about the existing system among the general public meant that social care reform became a vote-winner. It was only at the point at which the public largely wanted change that the political momentum grew to the point where reform was possible.

The first hurdle that England needs to jump is the low awareness and understanding of social care. Many people mistakenly believe social care to be part of the NHS and, therefore, free at the point of use. Given that the vast majority of people don’t know what social care is until they need it, plus only a proportion of us will ever need to draw on it, whenever politicians have proposed a new revenue stream, there has been a widespread misunderstanding that this represents a new charge for something that is currently free.

Create a collective positive narrative

In Germany and Japan, the narrative around reform was collective, broad and largely positive. In contrast, discussions about reform in England have almost always started with funding. Funding is, of course, essential but as the starting point, it anchors the debate firmly in cost. This rapidly takes the debate into the complex territory of who pays without properly articulating what sort of system we are aiming to create. In England, too, the debate has been dominated by a focus on older people and inheritance which overshadows the fact that a third of people drawing on local authority support are under 65 and that problems in the system extend beyond catastrophic costs.

While the narrative in Germany and Japan necessarily included discussion of unmet need and unpredictable costs, it also took on a broader framing which highlighted the benefits of investment in a new system for all. For instance, there was explicit recognition that a lack of supply of professional care not only had implications for the amount and quality of care but also had wider implications for the whole of society and the economy. High levels of unpaid caring impacts on people’s ability to work, volunteer and participate in communities. Indeed, in Japan the deliberate shift of responsibility for caring from families to wider society was very much driven by concern over a shrinking working age population. In both countries, the creation of a thriving provider market in social care was a key plank of economic development. By setting the debate in this wider context, reform was framed as of benefit to all, not just those in need of care.

Designing a fair a consistent system

Finally, the design of the systems – built around the principles of fairness, clarity and consistency – helped to cement public support. Both systems are underpinned by a financial ‘risk pool’ which means that everyone pays in to a central fund (in Japan contributions start at 40) and, on needing care, everyone can draw on benefits. Care is not free at the point of need but there is a standard schedule of benefits that are in proportion to severity of need. Everyone undergoes a consistent assessment process and those deemed to be eligible can access a monthly budget regardless of the cause of need (cognitive or physical), postcode, or affluence. This national approach to eligibility and benefits ensures consistency across the country and engenders a sense of fairness.

Prospects for change?

Covid has taken a heavy toll on social care but there is an opportunity to build something positive in its wake. Social care has been more prominent than ever during the pandemic and public awareness of its vital role in society has risen. The recent white paper set out a direction of travel that was mostly welcomed by those in the sector but that now needs to be followed by sufficient funding and sustained political will to bring about sustained change beyond minor tweaks to a broken system. But there is a risk that any steps forward will once again get stuck in the revolving door of reform if time and effort is not dedicated to embedding a positive narrative about the benefits for all of investing in social care.

Natasha Curry is Deputy Director of Policy at the Nuffield Trust, an independent health and care policy think tank. Natasha leads the Trust’s social care research programme and has an interest in what England can learn from other countries as it considers the future of its social care system. She has visited Japan and Germany to study their reformed social care systems. Natasha presented her research to the Commission and has written this blog as a guest contributor.