The market failure of social care: using England as a case study to explore unmet need

Social care provision is essential for ensuring the well-being and dignity of vulnerable populations. Addressing the challenges in social care system is critical for the sustainability of public health and the welfare system. This thesis focusses on key policies questions for social care in England. Specifically, it examines the need, demand, supply, utilisation, and unmet need resulting from the market for social care and, relatedly, health care (i.e., the broader ‘care’ market). Chapter 1 introduces the social care market and associated key policy problems, including a description of the unaffordable costs of care, vulnerable care supply, workforce shortage, and fragmented health and social care. To tackle these problems, it is important to accurately identify, estimate, or predict the care need, demand, supply, and utilisation in a current care system or for future cases. Chapter 2 presents the development of a conceptual framework with a set of working definitions for these key concepts to aid any empirical analysis. The framework and working definitions provide a theoretical foundation to distinguish the concepts (i.e., need, demand, supply, and utilisation), suggested indicators for measuring each concept, and explores sources of unmet need. Chapter 3 explores which factors have been associated with need, demand, utilisation, and unmet need in the literature via a systematic scoping review. Based on the theoretical foundation built within Chapter 2 and the existing evidence found in Chapter 3, predictors and predictive models of need, utilisation, and unmet need are developed in Chapter 4 and Chapter 5, using data-driven methods applied to cohort data from community-dwelling older adults. The predictive models identified in Chapter 5 are then applied to simulated cohorts in Chapter 6 to estimate need, utilisation, and unmet need in general older populations in England; policy-relevant scenarios are simulated to understand the potential impact of changing population characteristics (e.g., if frailty severity levels on average changed, how this may impact levels of unmet need). Findings from this thesis suggest that social care in England, as a market involving both the private and public sectors, has shown some signs of market failure. The data-driven predictive models identified in this thesis suggest that the current system might only be able to cover the worst-off, resulting in those who need help but ineligible for publicly funded social care having unmet need. Policymakers should carefully consider whether neglecting this group will worsen the existing pressures in both the health and social care sectors when people with unmet need in social care require acute healthcare or future, more intensive social care.