To realise the values articulated in Chapter 2, in the context of the supply and demand pressures set out in Chapter 3, policy makers in the four nations have instituted a series of reforms. These have focused on questions such as:

• • How should care be funded and allocated (including more individualised approaches)?

• • Who should access it and when (including efforts to delay or slow down formal access to care through preventative and asset-based approaches)?

• • How should it be integrated with health?

• • How should people providing care (unpaid carers and the paid workforce) be supported?

In this chapter we look at what Pollitt (2002) calls ‘decisional convergence’ around adult social care in the four nations. In Chapter 2 we looked at discursive convergence on what social care is for, highlighting the goals of wellbeing, fairness, rights and quality as the basis of a sustainable care system. In focusing here on decisional convergence, we look at the following mechanisms that have been used in all four nations across the previous 25 years. These are:

• • redistribute the costs of care

• • personalise support

• • support unpaid carers

• • invest in prevention

• • integrate with health

• • professionalise the workforce.

All of these policies are priorities in the four nations, but the balance between them and the specific policies introduced vary. Chaney (2022), in his analysis of 20 years of manifesto commitments on social care in the four nations, finds that the manifestoes of English parties focus on funding solutions, whereas in Wales the foremost issue is integration with health. Addressing care worker pay and conditions is the lead social care issue in party manifestoes in Scotland and Northern Ireland. We discuss these issues and the balance between them in the sections that follow.

Redistribute the costs of care

The question of who should pay for social care has been one of the big unresolved public policy issues of recent decades. Whereas health is provided free at the point of use by the NHS, social care has to be purchased privately by individuals who have assets above the means test threshold. In all four jurisdictions, it is recognised that the funding system requires reform, as set out in Chapter 2.