Decisions about arranging and paying for residential care among potential self-funders and their loved ones

The Department of Health and Social Care commissioned Ipsos to conduct a study on the likely uptake of Section 18(3) of the Care Act 2014 which at the time of this research was due to be extended to enable self-funding care users (self-funders) to ask local authorities to commission a care home place to meet their eligible needs. This research was commissioned under the previous administration (11 May 2010 to 5 July 2024) and the Section 18(3) policy is not being taken forward at this time. However, the insights from the research and the methodology which explored decision making and factors influencing choices made when accessing residential care are still relevant.

Currently self-funders are likely to pay higher rates for a care home place. The planned policy would have allowed self-funders to access the same rates as state-funded care users although they would continue to bear these costs themselves. It would also have increased the number of people for whom the local authority commissions care. In practice, where a person requested that their local authority commission their care under Section 18(3), the local authority would have offered options which it would put in place for someone eligible for local authority funding. This research aimed to estimate (in broad terms) likely take up of planned Section 18(3) policy by those entering residential care for the first time as well as provide insight into decision making factors.

The research involved a survey which ran from 30 March to 5 April 2023. The survey was completed by 1,290 eligible KnowledgePanel panellists who were either potential self-funders aged 65+ and not yet receiving care, or panellists who may need to arrange care for a potential self-funder in the future. The survey asked about whether they would explore options with the local authority and about the likelihood of taking up an offer of a care home place arranged by the local authority. It also included a Discrete Choice Experiment (DCE) that asked a yes/no take up question, based on a randomised combination of attributes and cost savings for the care home offered by the local authority. This was designed to enable analysis of what drives take up behaviour. The DCE was supplemented with a ‘behavioural model’ that also included varying care home attributes and cost savings. Lastly, the survey collected information about attitudes and concerns around organising care.

Following the survey, DHSC commissioned Ipsos to conduct a series of follow-up in-depth interviews with 15 participants. The aim was to understand in more detail how people plan for organising and paying for care, and the factors that influence their decisions.

Key findings:

• There was uncertainty surrounding the uptake of S.18(3) because the information people have on S.18(3) and its impacts on the care received would affect take up. Nonetheless, about three-quarters of participants would involve the local authority in exploring the options for care for themselves or their relative to understand more about the offer.
• The care home on offer through the S.18(3) route would likely affect whether self-funders ask the local authority to go ahead and arrange the care. The attributes of the offer which most affected potential uptake were the quality of the care (CQC rating), whether the location is near their preferred area or not, the quality of the facilities and the overall weekly costs and savings. 
• Participants in the qualitative interviews had a clear set of considerations about what they would be looking for in a potential care home, including widely accepted views on the quality of care and facilities (attitude of staff, cleanliness, activities, food), as well as views specific to their preferences (e.g. location and ambiance). 
• Survey participants thinking about care for themselves when moving from the community showed a lower preference for S.18(3) than other groups. Thus, uptake of S.18(3) would have been more likely when a relative is arranging care on behalf of someone or when the person arranging their own care is in a challenging situation with limited options (e.g. coming out of hospital).
• For survey participants considering care for themselves, a greater motivating factor for taking up the policy is concern about their ability to pay for the care, whereas for those arranging care on behalf of a relative, preserving their assets is more important.
• The survey showed that uptake is likely to be higher in local authorities where there are higher levels of trust in the local authority among self-funders.
• Participant confidence and trust in the local authority’s ability to arrange care that met the requirements of the person needing the care had a positive influence on intention to take up an offer of care arranged by the local authority. However, interview participants were cautious about the capacity of local authorities to appropriately arrange care that met the needs of the individual. These perceptions were a barrier take up of S18(3).

Male, aged 65+ asked about care or others, for whom the decision to take up S18(3) would depend on the offer: 

(...)I would like to think they would have my best interests at heart, but then again I know the pressure they're under so, or I think I know the pressure they're under or one perceives the pressure they're under. I wouldn't know whether to fully trust what they're offering.

• In designing the communications plans for this policy or similar policies relating to paying for care and preparing local authorities for implementation, it would be important to consider how and when to communicate information about the policy to overcome any trust issues.

More information on the factors influencing take up, as well as the methodology including details about the Discrete Choice Experiment, can be found in the full report. 

More detail on the findings from both stages of the research can be found in the reports below.

Reuben Balfour and Margaret Blake who led the research have also published a blog with their reflections on the research methodology.