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We can’t put off the reform of our social care system any longer

It’s not meeting our increasingly elderly society’s needs and finding a workable long-term solution is crucial

Louise Prime

Thursday, 12 September 2019

It is crucial that we find a long-term workable solution to adult social care in England with its increasing number of elderly and falling proportion of working-age adults, and reform cannot be put off any longer, the Nuffield Trust has warned. It has urged policymakers to start a positive dialogue about social care and told politicians to cross political divides to find a workable long-term solution – and in its latest report*, it recommended that England should learn lessons from the system in Germany.

The report’s authors pointed out that the current adult social care system in England is widely regarded as unfair, complex, confusing and failing to meet growing care needs in the population; and the impact of cuts that have resulted from a decade of austerity, as government funding for local authorities halved in real terms between 2010–11 and 2017–18, has been felt widely. They added that the prime minister has made it clear that he wants to “fix social care”.


The charity said yesterday that England’s social care funding today resembles Germany’s previously complex and fragmented system. Although more than four times as many people can now access subsidised long-term care in Germany as in England, this wasn’t always the case. Germany was in a similar situation 24 years ago, but successfully brought about far-reaching reform – the growing challenges of an ageing population and rising costs of care led to the introduction of its current system in 1995.

The German system’s main principles are: risk-pooling (social insurance spreads the risk across society to protect individuals from catastrophic, but not all, costs; transparency (contributions are levied on income and strictly ring-fenced); consistency of eligibility according to need, regardless of age, means or diagnosis; clarity of benefit (a fixed schedule of benefits according to need guarantees a minimum level of care to all, but individuals are expected to contribute to costs); stability for providers, creating a buoyant and competitive market; and fairness.

The report’s authors found that although the German system has much to be admired there are some cautionary tales. For example, it is heavily reliant on informal carers for its sustainability because the system only covers partial costs, benefits have not kept up with the actual costs of care, and many people find they’re unable to fund the rising costs of care. Furthermore, it is facing workforce shortages because “despite initially boosting workforce numbers after the new system was implemented, the government has reportedly been slow to react to growing vacancies”.

The Nuffield Trust authors identified nine lessons from Germany that they said can contribute to the debate on reforming England’s system. Their key recommendations are:

  1. There will be no progress without strong political leadership and cross-party cooperation.
  2. Secure public support by designing the system for transparency, clarity and fairness.
  3. Carefully balance cost containment with individual responsibility.
  4. Support long-term financial stability by balancing strict ring-fencing of revenue with flexibility.
  5. Create a strong provider market by balancing stability with local flexibility.
  6. Plan long-term and across government to address workforce pressures.
  7. Cash benefits can promote autonomy but may have unintended consequences.
  8. Join up policy to care for carers.
  9. Social care needs to be part of a bigger vision: building sustainable communities.

They concluded: “While we can learn a huge amount from the systems and experiences of other countries, a new social care system in England needs to suit this country’s social and cultural context and trends. Far from advocating for a wholesale adoption of Germany’s system, we would urge a thoughtful approach to identifying elements that might work for England while being mindful of the long-term consequences of some of Germany’s original decisions. The mechanisms and system design will necessarily be different, but the fundamental principles upon which Germany’s system is based – fairness, transparency, consistency, stability and sustainability – are ones that provide strong foundations for the next stage of debate. There is also much to be learnt from the policy development process Germany adopted to bring about comprehensive system change.”

The Nuffield Trust said projections of demographics and needs suggest that we must rethink our approach to care, and focus on preventing deterioration and keeping people independent within supportive communities. It insisted that debate around the future of social care should include how it supports and works alongside all other public services, as well as wider society, to promote wellbeing and independence.


It warned in a Tweet: “One thing is for certain: we can’t put off the reform of our social care system any longer. It’s not meeting the needs of our society and with an increasing elderly population and decreasing number of working-age adults, finding a workable long-term solution is crucial.”


*Curry N, Schlepper L, Hemmings N. What can England learn from the long-term care system in Germany? Research report, Nuffield Trust. Published online 11 September 2019. ISBN: 978-1-910953-68-6.

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