Bo Hu, Raphael Wittenberg, Jae Yeon Lyu, Derek King
Social care is crucial to the well-being of older people who need help with everyday tasks such as eating and bathing. In most high-income countries, people receive formal care provided by professional caregivers, unpaid care provided by family, friends and neighbours, or both. As people are living longer, more people will need social care in England, while the supply of informal care for older people seems unlikely to keep pace with the rise in demand, resulting in a gradual shift from unpaid to formal care. It is important to make sure that the provision of formal care is well-planned and that there is sufficient care for people with care needs. Understanding how demand for formal care services responds to changes in unpaid care is the key to fulfilling these goals.
The Care Act 2014 introduced important changes to eligibility criteria for government-funded social care in England. Before this legislation, the social care system was ‘carer-sighted’: people living with a family carer or receiving unpaid care might not receive any government-funded care and support at all. The Care Act 2014 stipulated that the determination of eligibility for government-funded care should not depend on the availability of unpaid care and depend exclusively on a set of quality-of-life outcomes such as managing personal hygiene and maintaining a good home environment. Only after people have been assessed to have eligible care needs, the availability of unpaid care should be considered, which determines the level of support offered.
Given the carer-sighted nature of the social care system before 2015, we expected that unpaid care substituted formal care during this period. We analysed data from the Health Survey for England (HSE) collected between 2011 and 2014, and the results confirmed our expectation: older people were less likely to receive formal care if they had access to unpaid care. Such a relationship was observed among older people receiving personal care and domestic care. Personal care refers to hands-on assistance with daily activities such as eating, dressing, and bathing, whereas domestic care refers to help with daily tasks such as taking medication, managing bills, shopping, and cleaning.
Using the HSE data, we also investigated the receipt of care after 2015. On the one hand, there was no longer a marked difference in the receipt of formal personal care between people who received and did not receive unpaid care. We found no evidence that unpaid care substituted for formal personal care. On the other hand, older people were still less likely to receive formal domestic care if they were receiving care from unpaid carers.
Recipients of personal care usually had a higher level of care needs than people who received only domestic help. People with personal care needs could be eligible for government support after the implementation of the Care Act 2014, even though they had access to unpaid care. Therefore, the substitution between personal care and unpaid care has been weakened since 2015. In comparison, people who only had domestic care needs were unlikely to be eligible for government support before or after the Care Act 2014, so the substitution between unpaid care and formal domestic care remained strong.
Overall, formal home care and unpaid care for older people substitute each other in England. However, there are signs that such a relationship has been attenuated since 2015. It can be argued that the social care system has become increasingly ‘carer-blind’ in the wake of the reforms of the eligibility criteria. This trend is most noticeable among older people receiving personal care.
Bo Hu, B.Hu@lse.ac.uk
