Implementing England’s Care Act 2014: was the Act a success and when will we know?

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Emily Burn University of Birmingham, UK

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Sam Redgate Northumbria University, UK

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Catherine Needham University of Birmingham, UK

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Stephen Peckham University of Kent, UK

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Many countries are reforming long-term care to deal with the social risks created by demographic and social change. However, the passage of legislation is often followed by a new set of challenges as policy is implemented. This article examines England’s Care Act 2014 through Compton and ‘t Hart’s criteria of policy endurance to demonstrate the importance of assessing effectiveness at multiple time points. Early success in ‘implementation readiness’ was followed by the abandonment or dilution of key commitments. Yet, the Act’s foundational principles – well-being, prevention and capping private spending – continue to shape care policy, much as its original supporters hoped.

Abstract

Many countries are reforming long-term care to deal with the social risks created by demographic and social change. However, the passage of legislation is often followed by a new set of challenges as policy is implemented. This article examines England’s Care Act 2014 through Compton and ‘t Hart’s criteria of policy endurance to demonstrate the importance of assessing effectiveness at multiple time points. Early success in ‘implementation readiness’ was followed by the abandonment or dilution of key commitments. Yet, the Act’s foundational principles – well-being, prevention and capping private spending – continue to shape care policy, much as its original supporters hoped.

Introduction

Many countries are reforming their long-term care systems to deal with the new social risks created by demographic and social change. These large-scale reforms can be hard won, for example, Japan’s reform of aged care was ‘the culmination of some 30 years of deliberation’ (Lai, 2002: 5). They are often heralded by their advocates as the beginning of a new era: Australia’s National Disability Insurance Scheme was greeted as ‘a major paradigm shift’ (Green and Mears, 2014: 25). However, the passage of legislation is often only the beginning of a new set of challenges as policy goals are translated into practice. A vast literature attests to the wide variety of factors that can affect implementation and lead to unexpected outcomes as policy aspirations and ideas interact with the complexity of organisational settings (see, for example, Pressman and Wildavsky, 1973; Lipsky, 1980; Kingdon, 1984; Sabatier, 1986; O’Toole, 2000; Hupe and Hill, 2016). In this article, we discuss the Care Act 2014 in England – a wide-ranging piece of legislation that sought to improve adult social care provision – to highlight the importance of reassessing the success of policy reforms at multiple time points.

Adult social care refers to the personal care and support that is intended to promote the independence and well-being of older people, disabled people, people with mental health problems and unpaid carers. In England, the national government establishes the legislation and policy that informs social care. Local governments have responsibility for overseeing social care systems within their areas and for commissioning and monitoring the provision of care from a variety of providers (Hudson, 2021; Humphries, 2022). The Care Act 2014 was an ambitious piece of legislation aimed at reforming the funding and provision of adult social care in England – a policy area known for its complexity (for an introduction to the Act, see Social Care Institute for Excellence, 2021). Implementation required stakeholder engagement at multiple levels: the macro (national), meso (regional) and micro (local government, service users, care providers and staff) (Hunter et al, 2020). The Act was backed by an implementation support programme (ISP), a relatively new government initiative that aimed to create a conducive environment for effective implementation. This programme, which ran from 2013 to 2016, was found in a national evaluation to have achieved its aims (Peckham et al, 2019). Yet, despite this preparatory work on implementation readiness, almost a decade on from the Act, it is clear that most of its goals have not been achieved. The Act’s funding reforms were abandoned, the number of carers’ assessments has fallen below expectations, individualised care funding has stalled and investment in prevention has been deprioritised (House of Commons Library, 2017; Health and Social Care and Housing, Communities and Local Government Committees, 2018; Tew et al, 2019; Fernández et al, 2020; Health and Social Care Committee, 2020; Bottery and Ward, 2021).

This article considers the success of the Care Act through a temporal lens, using Compton and ‘t Hart’s criteria of policy endurance. It explores the apparent early success of the ISP, the later failings in key elements of implementation and the enduring symbolic importance of aspects of the Act (for example, its focus on well-being and prevention) to illustrate how assessments of success fluctuate over time. It draws primarily on three research projects that evaluated different aspects of the implementation of the Act. It highlights how an assessment of policy success can benefit from incorporating a temporal dimension, which can account for the contextual changes that may affect ongoing policy implementation. In other words, we should consider how the relative successes of a policy might vary over time in response to complex shifts within the wider policy environment. In doing so, the article also contributes to the understanding of implementation as an unfolding process, which cannot be captured through ‘snapshot’ evaluations.

The Care Act 2014

Adult social care services provide support with the activities of daily living for people who have a long-term illness or disability, or who provide unpaid care. Their delivery sits within a complex policy environment. In England, the national government sets the legislative context, while local governments undertake the needs and means assessments that assess eligibility for care, and arrange support for people who meet the assessment criteria. Most care is provided by the private sector, and a substantial proportion of people purchase their own care, as they have assets above the means-test threshold, that is, the level of assets at which a person is required to fund their own care and support (Hudson, 2021). Discussions on the future of social care funding have been ongoing, with little resolution, across successive governments (Kings Fund, 2021), and this uncertainty, along with wider funding pressures, has affected the sustainability of social care markets in England (Humphries, 2022).

The Care Act 2014 was a significant and broad piece of legislation. It substantially reformed and consolidated existing social care statutes, placed a number of duties on local authorities and established new rights for people accessing services and carers. Local authorities in England were assigned a broad well-being duty (a principle to promote the quality of life of an individual who draws on support) and the responsibility to ensure the availability of a wide variety of good-quality social care services for people who need them. There was a shift in emphasis from commissioning services towards meeting local population needs. Local authorities were given a market-shaping duty (the responsibility to understand and stimulate local care markets) and new requirements to invest in prevention (that is, activity to reduce or delay future demand for long-term care), support unpaid carers and extend the take-up of personal budgets (a set amount of local authority funding that facilitates choice and control for individuals) (see Part 1 of the Care Act 20141). A limit on financial liability – sometimes called the ‘care cap’ – was introduced to set the amount that an individual who pays for their care can be expected to contribute over their lifetime. Four distinct stages can be identified within the evolution of the Care Act 2014. The stages indicate shifts and slippages in the implementation of the Act.

Stage 1: The development of legislation and the ISP

Between 2008 and 2011, the Law Commission – a statutory independent body that reviews legislation in England and Wales – assessed the confusing array of social care law in response to a government request. Following the publication of a scoping report, the Law Commission (2011) conducted a consultation of the sector to gather feedback on provisional proposals and established a series of recommendations that informed the development of the Care Act 2014. The drafting of the Act was seen to be an unusually inclusive process, bringing in key stakeholders to help shape an ambitious piece of legislation. Humphries (2022: 49) notes that the Act was ‘widely acclaimed’ within the social care sector and offered ‘a ray of hope’.

There were two parts to the Care Act, each of which had a different implementation timetable. The first part came into force in April 2015 and included the main local authority duties around well-being, prevention, market shaping, support for carers and individualised funding (National Audit Office, 2015). The second part, introducing the cap on care spending by private individuals, was scheduled for implementation in 2016. This staged approach to implementation stemmed from an explicit temporal rationale, namely, that there was a need to build capacity and readiness within the sector for the wide-ranging changes to the care market that the care cap would trigger.

To support the Act’s implementation, the Department of Health, the Local Government Association and the Association of Directors of Adult Social Services (ADASS) established the ISP to provide ‘the support necessary to carry out this challenging piece of legislation’ (National Audit Office, 2015: 7). The ISP aimed to clarify the requirements within the Act, as well as develop resources to support implementation. The programme was also designed to facilitate collaboration and provide a channel of communication between the local, regional and national levels (Peckham et al, 2019).

An evaluation of the ISP, funded by the National Institute for Health and Care Research (NIHR), found that, overall, it had been successful (Peckham et al, 2019; 2022). There were some limitations, for example, operational staff did not always receive information from senior managers and frequently had to rely on their own interpretation of policy, which had the potential to increase confusion and lead to inconsistencies in implementation (Peckham et al, 2019). However, despite this limitation, the programme was assessed to have improved ‘implementation readiness’ (Peckham et al, 2019), and local authorities were felt to be in a good position to implement the Act. A key strength of the programme was the facilitation of communication between local authorities and central government, and enhanced regional-level support.

Stage 2: Delay of Part 2 of the Care Act

While Part 1 of the legislation was introduced according to the planned timetable, Part 2 (the care cap) was not. The requirement of sector ‘readiness’ for the financial changes proved to be a difficult criterion to meet. Following concerns expressed by local governments about the viability of implementation, the cap was first delayed (Prior, 2015) and then dropped in 2017 (Doyle-Price, 2017; House of Commons Library, 2017).

Stage 3: Ongoing implementation of the Care Act

Despite the abandonment of Part 2 of the Act (the care cap), the implementation of Part 1 continued. The NIHR commissioned three projects to consider the implementation of specific elements of the Act: one looked at market shaping and personalisation (Needham et al, 2020); a second looked at prevention (Tew et al, 2019); and a third focused on rights for carers (Fernández et al, 2020). The broadly positive findings of the ISP evaluation (discussed earlier) were not matched by these subsequent studies. Findings from these projects underlined the challenges local authorities encountered when implementing the Care Act. The project on market shaping and personalisation found that local case sites had made limited progress. Working to develop a strategic approach to market shaping and personalisation was hindered by long-term funding uncertainty, recruitment challenges and local authority restructuring, which increased the instability of social care markets (Needham et al, 2020). The prevention evaluation (Tew et al, 2019) found that a range of initiatives had been undertaken; however, the challenging financial context inhibited sustained investment in preventative approaches. Fernández et al (2020) examined the support available to, and accessed by, carers. While the importance of carers’ well-being was recognised, the evaluation found that this was not converted into an increase in service access, as local authorities sought to manage demand within a challenging financial context. Instead, support was focused on carers who were providing the most intensive levels of care. The number of carers’ assessments, a key commitment in the Act, had gone down, rather than up, since 2015.

Stage 4: The revival of the care cap

The fluctuating fortunes of the Care Act were again highlighted in 2021 when the government announced plans to finally implement the Care Act’s cap on care spending, subject to some modifications. The Health and Care Act 2022 legislated for an amended version of the cap, noting: ‘Legislation to allow a cap on care costs was already in place in the Care Act but implementation was postponed’ (Section 6.166 of the Heath and Care Act 2022). The government also proposed a health and social care levy, a separate, new tax, which would provide funding for the care cap, among other things (HM Government, 2021). However, optimism about finally achieving a version of the care cap was dimmed later in 2022 when, first, the health and care levy was abolished and then it was announced in the Chancellor’s autumn statement that the care cap would be delayed until October 2025 (HM Treasury, 2022). As in 2017, a key reason for delay was concern within local government about not being ready for ‘the financial and operational implementation challenges’ (County Councils Network, 2022). The twists and turns in the Act’s implementation affirm that, as noted by Manthorpe (2021), despite the political consensus directed to the Care and Support Bill, the Care Act has not addressed the wide-ranging challenges facing adult social care in England.

The lack of achievement in key areas may suggest that the Care Act has failed in its aims. However, the three underpinning principles of the Act remain influential in contemporary policy debates and suggest that the Act continues to have resonance. These are: the commitment to well-being as the goal of social care rather than a narrow functional view of care; the investment in prevention rather than responding to crises; and the promise to place social care on a more secure and fair financial footing. Marczak et al (2022: e1715) note that the Care Act ‘legitimised the definition of carers as clients’, or a group of people who should receive support, even if this ‘did not necessarily translate into more tangible assistance’. Well-being and prevention are key themes in the ‘Integration and innovation: working together to improve health and social care for all’ and ‘People at the heart of care: adult social care reform’ white papers (Department of Health and Social Care, 2021a; 2021b). The care cap continues to be government policy – and indeed has now been legislated for twice, with planned implementation in 2025.

This brief summary of the Care Act timeline highlights the importance of considering policy implementation through a temporal lens. The apparent success of the ISP in Stage 1 did not translate into successful implementation in Stages 2–4, and yet the principles underpinning the Act continue to inform policy discussions and the funding proposals remain in place for 2025 (for now). This leaves us to question on what grounds and when we should assess the success of a policy.

The temporal challenge of assessing success

The policy implementation literature has identified a number of approaches through which the success of implementation can be assessed. There are the ‘top-down’ versus ‘bottom-up’ accounts of implementation forces, as well as hybrids of these (Howlett, 2019). There is the focus on the policy itself, most famously, its ambiguity and complexity (Matland, 1995). There is a newer concern, emerging from implementation science, with system complexity (Braithwaite et al, 2018), which requires public services to be analysed via a ‘processual and systemic’ frame (Osborne and Radnor, 2016: 56).

Here, we want to highlight the importance of also giving attention to the issue of when an assessment of implementation success is made. Moran (2001: 179) makes the point that ‘judgements about success and failure are highly sensitive to the moment when we make the judgement’. Pollitt (2008: 140), in his book about time in public policy, notes: ‘certain programmes which may appear highly problematic after a couple of years (when most evaluations tend to be done) bed in and move up the learning curve to become relatively successful a few years later’. In particular, as ‘t Hart and Bovens (1996: 23) argue: ‘Short-term effects are also more easy to register than long-term effects which are likely to become intertwined with other phenomena in complex and often unintended ways. Moreover, short-term and long-term effects may in some cases be at odds with one another, the latter reversing or neutralising the former’.

Compton and ‘t Hart (2019: 4) acknowledge the complexity of establishing whether a policy has been successful, noting: ‘policy assessment is necessarily a multi-dimensional and multi-perspectivist, and political process’. To account for this complexity, they suggest a range of criteria of assessment, including the relatively neglected notion of ‘endurance assessment: the extent to which the achievements and success of a policy are maintained’. This dimension of Compton and ‘t Hart’s framework sensitises us to the timing element of any policy assessment. Policy success should be assessed not through a ‘one-off snapshot but as a multi-shot sequence … ascertaining how its performance and legitimacy develop over time’ (Compton and ‘t Hart, 2019: 5). They suggest that a temporal focus requires attention to:

  1. the degree to which the policy confers legitimacy on the broader political system;
  2. the degree to which the policy’s programmatic, process and political performance is maintained over time; and
  3. the endurance of the policy’s value proposition (that is, the proposed ‘high-level’ ends–means relationships underpinning its rationale and design, combined with the flexible adaptation of its ‘on-the-ground’ and ‘programmatic’ features to changing circumstances and in relation to performance feedback).

We used these three criteria to consider the success of the Care Act over time, drawing on the available evaluations of the Care Act implementation and the broader policy context.

Assessing the endurance of the Care Act

As discussed earlier, the implementation of the Care Act was originally planned to be in two parts and the context in which the Act was implemented changed across time. Exploring these changes in context helps us to understand the seemingly shifting fortunes of the Act. By synthesising the findings from the NIHR-commissioned projects undertaken at different points in the Care Act’s implementation, we draw out the influence of the wider context in which the Act was implemented. In particular, we look at how different stages of implementation relate to Compton and ‘t Hart’s criteria outlined earlier.

Conferring legitimacy

The ISP that accompanied the Act can be seen as a key element of conferring legitimacy (Hunter et al, 2020). Peckham et al (2019) found that the ISP facilitated close collaboration between key actors and generated broad consensus directed to the main aims of the Act. Stakeholders were found to broadly support the principles of the Care Act, and this fostered a sense of investment in the support programme that facilitated ‘productive conversations … that may have more commonly been adversarial’ (Peckham et al, 2019: 72). The programme helped to secure endorsement of the ‘value propositions’ (Compton and ‘t Hart, 2019: 6) within the Care Act and offered a mechanism by which the rationale and legislative means were accepted.

The ISP benefited from strong collaboration across three key national bodies heavily involved in the implementation of the Care Act: the Department of Health, the Local Government Association and ADASS. The partnership working embedded within the ISP prompted Peckham et al (2019) to classify the programme as an example of collaborative policy design (Ansell et al, 2017). Ansell et al (2017) make a case for pursuing collaborative policy design in order to strengthen implementation. Policy design, or the development of ‘visions, goals, causal assumptions, rules, tools, strategies and organisations to address a particular policy problem’, should be built on ‘collaboration and deliberation between upstream and downstream actors’ (Ansell et al, 2017: 468–9). These collaborative and deliberative actions enable stakeholders to share knowledge and experience, which can also promote innovation and lead to more effective policy and subsequent implementation (Sørensen and Torfing, 2011). Collaboration in policy design can also promote a sense of ‘joint ownership’ (Ansell et al, 2017: 476) and support for policy solutions. Collaborative policy design is a continuous process of ‘adaptive implementation’ (Berman, 1980, quoted in Ansell et al, 2017), where the new knowledge and data generated by implementation is fed back into the adaption (or further design) of policy. The communication facilitated within the ISP encouraged collaboration to address identified problems and concerns, and, as a result, developed stakeholder support for the legislation.

This spirit of collaboration was also found within the ISP’s facilitation of shared learning between national and local government. Peckham et al (2019) highlighted that within dispersed governance, effective implementation requires links to be forged between national and local levels. Within the ISP, regional coordinators fulfilled this function by facilitating communication and information exchange between central government and local agencies – a complex task that required regional co-ordinators to engender trust and project credibility. The connections between national and local levels facilitated feedback on the implementation of the Care Act and allowed elements of the ‘flexible adaptation’ of policy that contributes to the continued endorsement of a policy (Compton and ‘t Hart, 2019: 6).

The ISP provided a mechanism that facilitated collaboration on, and endorsement of, the value propositions of the policy. However, some elements of the legislation lacked definition. This lack of clarity may have meant that it was easier for key components of the legislation to be accepted. Peckham et al (2019) draw on Matland’s (1995) discussion of how the specific qualities of a policy can affect its implementation. With regards to the Care Act, there was a broad consensus over its principles; however, there were ‘some new and largely untested ideas that were always likely to be open to interpretation’ (Peckham et al, 2019: 115). Needham et al (2020) found a variety of interpretations of the key term ‘market shaping’ and a lack of benchmarks as to what constituted ‘good’ market shaping. This lack of clarity within the Care Act was found to have hindered its implementation, as the different interpretations of these concepts challenged the aim of the Care Act to increase consistency across the social care system. Peters’ (2015: 12) exploration of policy coordination makes a distinction between policy development and its administration. The Care Act can be seen as representing Peters’ vertical dimension of policy coordination, where central government is dependent on local authorities to implement reforms to social care. Legislative ambiguity meant that local authorities were pursuing their own version of market shaping and challenged policy coordination. Furthermore, analysis of parliamentary debates on the Care Bill found that there was a lack of clear differentiation between services intended for carers and services for people with care needs (Manthorpe et al, 2019; Fernández et al, 2020). This blurring had the potential to affect local authority charging policies, with carers potentially charged to access services in some areas and not others (Fernández et al, 2020: 14–15).

In summary, the ISP was found to have enhanced the legitimacy of the Care Act, though there remained a lack of clarity about key elements within the Act. As one of the first ISPs used by the government, the model was found to be an effective one for supporting implementation readiness (Peckham et al, 2019) and for conferring legitimacy across the system ahead of full implementation.

Programmatic, process and political performance

A second dimension of the temporal assessment of policy identified by Compton and ‘t Hart (2019) is the extent to which the performance of the legislation is maintained over time. A series of projects, published five years after the Act, came to much less positive conclusions than the ISP evaluation. The care cap was postponed in 2015 and abandoned in 2017, contributing to widespread uncertainty about future funding (House of Commons Library, 2019b; Health and Social Care Committee, 2020). Needham et al (2020) identified that such uncertainty affected collaboration between local authorities and social care providers. Social care providers were hesitant to commit to long-term investment in their estates. Funding uncertainty was also found to contribute to a lack of coherence within local authorities’ approach to market shaping. For instance, self-funders were frequently treated as peripheral to market-shaping strategies, despite having a significant impact on the local care system (Henwood et al, 2022).

The elements of the Act that remained in place were found to have been patchily implemented. Short-term austerity and the real-terms fall in social care spending from 2009 to 2016 (House of Commons Library, 2019a) severely limited the impact of the Act. Fernández et al (2020: 20) found that carers’ access to support and information had increased but there was a drop in carer-specific services. Local authorities’ capacity to meet ‘policy ambitions with regard to carers therefore has been mediated by budgetary constraints as well as constant demographic pressures’ (Fernández et al, 2020: 22). Tew et al (2019) also found that the financial challenges presented by short-term austerity affected how local authorities responded to their Care Act duty to promote well-being and to prevent, reduce or delay the need to access social care services. While there were strong expressions of support for the principles of prevention, local authorities favoured short-termism and meeting existing demand. Furthermore, Tew et al (2019: 17) found that there could be a lag of between one and five years from the introduction of a preventative approach and the accrual of eventual benefits. This lag, and the expectation of annual cost savings, had the potential to jeopardise the continual investment required by a preventative approach. The pressure of short-term austerity steered local authorities towards prioritising meeting existing demand, rather than making the necessary investment in prevention.

While Needham et al (2020) and Tew et al (2019) noted that austerity had the potential to encourage greater innovation within social care services, in practice, local authorities were engaging in risk-averse behaviours that were focused on compliance. An objective of the Care Act was to foster the development of a vibrant social care market and encourage diversity in service provision in order to facilitate choice and control (Needham et al, 2018a; 2018b). In examining how local authorities have responded to duties placed on them to shape social care markets, Needham et al (2020) found that local authorities’ concern to secure the sufficiency of supply frequently precipitated a prescriptive approach that restricted individuals’ choice and control of services. Some local authorities had trialled practices like co-design that would respond to local variance and facilitate stakeholder learning; however, these attempts were hampered by uncertainty around funding and low levels of trust between commissioners and providers. Local authorities that were engaging most effectively with their local care systems had minimised the level of control and prescriptive rules in preference for provider- and community-led innovation. However, most were struggling to sustain this approach in a context of funding cuts. Trust can promote collaboration and sustain commitment to partnership working (Ansell and Gash, 2007; Ansell et al, 2017). However, the pressures of operating within a challenging financial context led some social care providers to adopt a defensive stance that sought to protect their business interests and restricted their willingness to engage in market-shaping activities (Needham et al, 2020). Furthermore, some local authority social care commissioners were wary of for-profit providers and expressed unease that providers expected to extract large profits when local authorities were operating within straitened financial circumstances.

Across the evaluations, the wider context of short-term austerity and uncertain long-term funding was found to affect internal and external stakeholder relations and local-level coalitions supporting the implementation of the Care Act. Particular difficulties within local authorities included the skill mix of staff, high workloads and a lack of staff continuity (Needham et al, 2020). Market shaping not only requires the involvement of social care commissioning teams but also necessitates the support of others across the local authority, such as procurement and legal teams, as well as such services as housing and planning. It requires a shift in culture to one that is permissive of greater risk taking and iterative learning. Some case sites had worked with providers and other stakeholders to co-design models of care ‘but had to abandon this approach due to internal resistance from legal and procurement teams and an inclination to emphasise contract price’ (Needham et al, 2020: 33). The strong relational skills and the capacity to develop associations of trust and shared learning were not found to be present in local case sites, despite the efforts in the ISP phase to build relationships.

There was also evidence that the challenging financial circumstances affected external stakeholder relations, which, in turn, affected the implementation of the Care Act. Tew et al (2019) found that collaboration was challenged by partners being motivated by different incentives. Health partners were focused on reducing delayed transfers of care from hospital, which risked the ‘inappropriate provision of expensive packages of nursing and social care that may be hard to disentangle’ (Tew et al, 2019: 7) and obstructed the integration of preventative approaches. Fernández et al (2020) identified increased collaboration between local authorities and the voluntary sector, which could expand access to low-level services that aimed to build the resilience of carers. However, within some case sites, it was suggested that this collaboration ‘sometimes masked strategies aimed at diverting people from using core social care services’ (Fernández et al, 2020: 29–30). Consequently, while the ISP had facilitated collaboration, the challenging financial circumstances had negatively affected relationships between local authorities, social care providers and wider stakeholders.

Endurance of the policy’s value proposition

The third element of Compton and ‘t Hart’s framework is the endurance of the significant ideas or principles that underpin a policy. In other words, whether a policy has an underlying symbolic value. The ISP generated broad agreement on the key principles of the Care Act that underlie a shared vision for social care. The three projects exploring local authorities’ response to the Care Act reveal its partial implementation, as discussed earlier. However, each project presents evidence for ongoing support for the key principles within the legislation. Fernández et al (2020: 14) found that the Care Act had legitimised an increased focus on meeting carers’ health and well-being at the service level. Furthermore, within Tew et al’s (2019) project, case sites expressed a commitment to promote well-being and build capacity for prevention. Needham et al (2020) noted that commissioners within local case sites recognised and supported the focus on well-being and the shift away from more functional and needs-based accounts of social care. Across the projects, the challenges of implementation were attributed to ongoing funding uncertainty and short-term austerity rather than reservations directed to the principles of the Care Act. Engaging stakeholders in the design of the legislation may help to sustain the principles and ideas that have informed the Act. The endurance of the key principles of the Care Act are also reflected in the most recent white papers from the Department of Health and Social Care (2021a; 2021b) – ‘Integration and innovation: working together to improve health and social care for all’ and ‘People at the heart of care: adult social care reform’ – which continue to emphasise the principles of well-being and prevention. Hence, while elements of the Care Act were dropped, or only partially implemented, the Act’s ‘value propositions’ (Compton and ‘t Hart, 2019: 6) appear to have an ongoing influence on policy.

Discussion

Applying Compton and ‘t Hart’s ‘multi-shot’ approach when assessing the success of the Care Act has conveyed the ‘policy content and situational variables’ (Ansell et al, 2017: 481) that affected the implementation of the Care Act and how these shifted across time. As discussed earlier, these variables can be broadly categorised as the effects of short-term austerity and long-term funding uncertainty, as well as the conditions of local care systems. Local authorities were operating within challenging financial circumstances that reduced trust between local authorities and social care providers, and limited collaboration. In an uncertain context, local authorities were risk averse and acted to retain tighter control over social care provision. Their scope to do so was limited by the complexity of care provision, involving multiple stakeholders. Crisis management was prioritised over the development of the longer-term strategic approach required to fully implement the Act.

Applying Compton and ‘t Hart’s temporal dimension when assessing policy success develops our understanding of how the wider context can affect implementation. As Howlett et al (2016a; 2016b) argue in their development of Kingdon’s (1984) multiple-streams approach, interactions between streams of ‘competing coalitions’ (Howlett et al, 2016a: 75) of actors can produce unexpected and messy outcomes as different streams rise and fall in prominence throughout the policy cycle. Building a coalition to support the principles of legislation is likely to be easier at the start of the policy process, where actors are given the opportunity to contribute to policy design. Evaluation of the ISP showed that coalitions were developed with the aim of ensuring implementation readiness. However, across time, it proved hard to hold these coalitions together due to the effects of short-term austerity and long-term funding uncertainty, as well as the conditions of local social care systems.

These coalitions were more fragile for being multi-level, as well as within levels of government. Exworthy and Powell (2004) highlight three potential coalition patterns in building policy coalitions: central–local; central–central and local–local. The ISP built vertical coalitions between the central and the local. However, the conditions of austerity undermined the extent to which horizontal local–local coalitions (for example, between local authorities and providers, or between local authorities and health partners) could effectively implement the legislation and reduced trust between local authorities and central government partners.

The temporal focus of Compton and ‘t Hart reminds us that the assessment of policy success is always ongoing and incomplete. Here, we have considered the ISP and synthesised findings from projects considering implementation ‘on the ground’. Taking the multi-shot approach allows us to identify that the policy was effective at conferring legitimacy in the short term and has been effective at sustaining its value proposition in the long term. Where it has not been effective is in Compton and ‘t Hart’s criteria of programmatic, process and political performance. The ongoing discussions about the future implementation of the care cap, over ten years after the Act itself, highlights that even an assessment of programmatic performance is not static. We may yet see success for a part of the Act that was previously abandoned.

The events of 2022 – the revival of the care cap followed by its delay – affirm the value of examining the question posed by this article (‘Was the Care Act 2014 a success, and when will we know?’). For as long as legislation is able to retain its value proposition, then it continues to be possible that its programmatic elements will be revived. This insight requires us to sustain the multi-shot approach advocated by Compton and ‘t Hart, revisiting at regular intervals the ongoing process of implementation.

Conclusion

The implementation of England’s Care Act 2014 has been examined here using a temporal framework to capture changing patterns over time. The analysis has contributed to our understanding of implementation within a complex, multi-level governance context, such as social care. Implementation is a long-term process and policymakers need to continue to engage with implementation in a reflexive way to identify shifts in context and consider how this may affect policy implementation. Although our focus here has been on England, we see the findings as having relevance to other jurisdictions as they attempt large-scale reform of their long-term care in complex and multi-level systems.

Applying the endurance dimension of Compton and ‘t Hart’s framework led us to consider the success of the policy across multiple time points. Social care policy implementation occurs in a complex system, necessitating vertical and horizontal coalitions, which shift over time. Writing about the Welsh legislation, which closely paralleled the English Care Act, Cooke et al (2019: 79) note: ‘The implementation of the Social Services and Well-being (Wales) Act 2014 will take years, decades even, and change will only come about if those in the social care sector are supported to evaluate and understand what is important in social care delivery and how to take the best approaches’.

The multi-shot approach advanced by Compton and ‘t Hart draws attention to taking this long view of policy implementation. The fortunes of the Care Act have ebbed and flowed. Its ISP – one of the first of its kind – was found to have been effective in creating implementation readiness. Detailed analysis of its key themes – market shaping, personalisation, carers support and prevention – found that many of the Act’s duties remain unfulfilled. The repeated abandonment of its funding reforms was a clear failing, though one that may yet be reversed. The foundational principles of the Act – a commitment to well-being, prevention and reforming the funding of care – continue to shape care policy, though there is still uncertainty as to how the social care system will realise these foundational principles. Even a decade on from its passage, we cannot give a summative assessment of whether the Care Act has been successful, and the extent to which it will come to be seen as a key intervention in which crucial concepts (well-being, prevention) and mechanisms (the cap) were introduced remains unclear.

There are limitations to the analysis presented here. Our assessment of the success of the Care Act was restricted to the research questions and scope of the evaluations on which we have drawn. The commissioned studies explored the implementation of the Care Act across local case sites. While attempts were made to secure a mixed sample, it may be that the local authorities recruited were more amenable to discussing the implementation of the Care Act in their area.

A key contention of this article is that the timing of an assessment will influence whether a policy is judged to have been a success. The COVID-19 pandemic has had a great effect on the commissioning and delivery of social care (Bottery, 2020; Dunn et al, 2020). The wider effects of this changing context are still emerging. Recent UK government announcements on care investment and the delay of the cap on spending by self-funders have added further turbulence and uncertainty. Again reflecting Compton and ‘t Hart’s endurance dimension, there is scope for further longitudinal analysis to assess the ongoing significance of the Act. While the Care Act was found to have been only partially implemented, the principles of the legislation continue to shape policymaking in the sector. This symbolic legitimacy could secure the continued influence of the Care Act on long-delayed reforms of social care funding.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme (PR-R14-1215-21004, ‘Shifting-Shapes: How Can Local Care Markets Support Quality and Choice for All?’, and PR-ST-1116-10001, ‘Shaping Personalised Outcomes – How Is the Care Act Promoting the Personalisation of Care and Support?’). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Conflict of interest

The authors declare that there is no conflict of interest.

References

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    • Search Google Scholar
    • Export Citation
  • Fernández, J.L., Marczak, J., Snell, T., Brimblecombe, N., Moriarty, J., Damant, J., Knapp, M. and Manthorpe, J. (2020) Supporting carers following the implementation of the Care Act 2014: eligibility, support and prevention, www.lse.ac.uk/cpec/assets/documents/cascfinalreport.pdf.

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    • Search Google Scholar
    • Export Citation
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    • Export Citation
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    • Export Citation
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    • Export Citation
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    • Search Google Scholar
    • Export Citation
  • Howlett, M., McConnell, A. and Perl, A. (2016a) Moving policy theory forward: connecting multiple stream and advocacy coalition frameworks to policy cycle models of analysis, Australian Journal of Public Administration, 76(1): 6579. doi: 10.1111/1467-8500.12191

    • Search Google Scholar
    • Export Citation
  • Howlett, M., McConnell, A. and Perl, A. (2016b) Weaving the fabric of public policies: comparing and integrating contemporary frameworks for the study of policy processes, Journal of Comparative Policy Analysis: Research and Practice, 18(3): 27389. doi: 10.1080/13876988.2015.1082261

    • Search Google Scholar
    • Export Citation
  • Hudson, B. (2021) Clients, Consumers or Citizens? The Privatisation of Adult Social Care in England, Bristol: Policy Press.

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    • Search Google Scholar
    • Export Citation
  • Hupe, P. and Hill, M. (2016) ‘And the rest is implementation’. Comparing approaches to what happens in policy processes beyond great expectations, Public Policy and Administration, 31(2): 10321. doi: 10.1177/0952076715598828

    • Search Google Scholar
    • Export Citation
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    • Search Google Scholar
    • Export Citation
  • Lai, O.K. (2002) Long-term care policy reform in Japan, Journal of Aging & Social Policy, 13(2–3): 520. doi: 10.1300/j031v13n02_02

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    • Search Google Scholar
    • Export Citation
  • Marczak, J., Fernandez, J.L., Manthorpe, J., Brimblecombe, N., Moriarty, J., Knapp, M. and Snell, T. (2022) How have the Care Act 2014 ambitions to support carers translated into local practice? Findings from a process evaluation study of local stakeholders’ perceptions of Care Act implementation, Health & Social Care in the Community, 30(5): e171120.

    • Search Google Scholar
    • Export Citation
  • Matland, R. (1995) Synthesising the implementation literature: the ambiguity–conflict model of policy implementation, Journal of Public Administration Research and Theory, 5(2): 14574.

    • Search Google Scholar
    • Export Citation
  • Moran, M. (2001) Managing reform: controlling the medical profession in an era of austerity, in M. Bovens, P. ‘t Hart and G.B. Peters (eds) Success and Failure in Public Governance: A Comparative Analysis, Cheltenham: Edward Elgar, pp 17183.

    • Search Google Scholar
    • Export Citation
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Emily Burn University of Birmingham, UK

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Sam Redgate Northumbria University, UK

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Catherine Needham University of Birmingham, UK

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Stephen Peckham University of Kent, UK

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