Building better social care

While we have started to hear more about the social care system in the UK, we hear much less about how social care is set up internationally, including from the countries that have reformed how care is organised in recent decades to include an element of universal coverage. Coming to social care reform late from an international perspective, we have the luxury of being able to learn from others’ efforts. At the moment, however, we proceed as if we are the only country that has faced the issue of how to fund and organise quality, fair access to care. How have they progressed while we haven’t? And what can we learn from them that might be transferable?

On November 16^th 2021, the New Economics Foundation, the Women’s Budget Group and Friedrich-Ebert-Stiftung hosted an online event exploring universal social care systems around the world. We heard from Professor Naoki Ikegami about social care in Japan, in Germany from Professor Hildegard Theobald and Sweden from Professor Marta Szebehely, and discussed what insights they hold for the UK.

Japan

Care services were first established in Japan in 1929, available for those with no money, no home, and no family. Despite a series of reforms, including the Gold Plan to extend services in 1989, services continued to be focused on providing support for the poor and people felt that social services failed to provide good long-term care.

The Long-Term Care Insurance (LTCI) system was introduced in 2000, expanding support to all in need regardless of income or the available of family help. It covers all those aged over 65 and those aged 40 – 64 with, for example, a related disease, with home-help, day care, specialist homes, equipment, and home improvements. Services are managed by municipalities and funded through a combination of general taxation and insurance premiums.

The LCTI has grown rapidly in Japan since its inception. The population of over 64s increased 1.4 fold, while the number of people eligible and using the service increased threefold.

Long-term care in Japan has different standards to healthcare. In social care, the imperative is to provide a decent level of service. Not an equal one. Decisions are made by care recipient, and care mainly provided by families, not professionals. Beyond short training, care workers don’t require a qualification process.

Sweden

The aim of the public social care system in Sweden is to deliver high quality services that are used by all social groups. There is a clear equality ambition built into its design, along with the notion that formal eligibility for care is not enough. Services also must be accessible, affordable and of high quality.

Homecare in Sweden was the first universal welfare service. Services were publicly funded and publicly provided. The system was accessible and affordable, and care workers had enough time, continuity, and freedom of action to provide individually adapted support.

However, inspired by the UK, there was a trend of privatisation. 20% of providers are now for profit. Equality legislation remains unchanged, but there has been a tightening of public funding leading to reduced service coverage. And because of trends inspired by new public management, care has become increasingly predefined, standardised, and fragmented. Policy in place promoting ageing has meant a decline in the number of care homes, which are popular in Sweden.

Despite this, services are still widely accessible. The maximum anyone will pay for care is £180 a month, and those with low incomes are exempt from charges. Most people still prefer publicly funded care to care provided by family or the market. There is still strong public support for publicly provided services and a willingness to pay tax to fund it.

Germany

Like in Japan, before the introduction of LTCI, access to care was means tested and based on the availability of family responsibility. Demographic change, increasing care needs and financial difficulties catalysed the case for change.

LTCI in Germany aims to be universally available for all ages. The basic idea underpinning the system is familialism – that is, publicly supported family care is complemented by formal care services. LCTI is funded by social and private insurance schemes. Payments are made at a flat rate of 30% of private costs, and so user fees are high compared to Japan and Sweden. There is means-tested assistance for private costs. Providers compete in a quasi-care market, the aim of which is to enable choice for those supported and to keep costs under control.

The introduction of LTCI extended care coverage. 18% of those aged over 65 now use care services. Informal care is still the primary means of support, but 44% of those with care needs use paid services. Eligibility for care has expanded over time and there is a general acceptance of increasing public funds to support the care system, which is now seen as an important pillar of social policy.

High private costs are a barrier for some with care needs, and there are regional differences in the availability of care. Services, especially home care, are standardised. Because of the lack of a collective agreement, there are differences in pay and training for care staff.

Key take away:

Each of the three social care systems had a number of key differences. The generosity of the public offer differed between countries, and so did the level of co-payments and user fees. Correspondingly, each country had differing levels of public spending on social care and a variety of ways of raising the revenue for this spending. Countries had different mixes of public, private and not-for-profit provision, as well as differences in focus on residential care and ageing in place policies.

What was clear from all three presentations, however, was that universalism is both possible and desirable. Where care support was previously means tested, services tended to be of poor quality. To avoid the problem identified by Richard Titmass, that ​‘services for the poor tend to be poor quality services’, long-term care services should be available to all and of sufficient quality that they are taken up. International practice shows that universalism like this is not unaffordable, and it can be achieved with the political will. As Marta Szebehely noted, universal long-term care is not just an expense. It should be seen as part of society’s social infrastructure.

Bob Findley Williams ended the session with a timely reminder that as well as universal entitlement, support should be organised according to independent living and people’s right to control where you live, who you live with and the kind of life you want to lead.