Putting the cart before the horse (yet again)
During the pandemic, the longstanding neglect of adult social care has been even more tragically exposed than before – and lots of people have been debating how things need to be different in future. While it’s great that so many people are at least talking about social care, it tends only to be the bits that touch the NHS (essentially care homes and services for older people), rather than social care in all its diversity and in its own right. Moreover, the recent funding debates have been so narrow as to be embarrassing.
As we wrote for the Local Government Association (when, tired of waiting, it produced its own Green Paper on Adult Social Care in 2018): “All too often the funding of adult social care is seen as an economic and a technical issue: what’s the best mechanism for raising the funding we need? While this is important, the more fundamental questions are personal, political and philosophical: what kind of life do we want to have together as a society? How much do we value disabled and older people with care needs? What sort of support would we want available to any of us if we needed care? How much do we really vale this and how much might we be prepared to pay for whatever quality of life we decide we want?
With the NHS, we recognise that none of us can predict in advance who might need to access health services, that care should be based on clinical need rather than ability to pay, and that we’re better off as a society when we all contribute to the cost of the service and all benefit when we need it. With social care, unfortunately, we have a system that few people understand, that is only really available for people with very significant needs and very low incomes, and that few people think about until they find themselves trying to access it in a crisis – never a good time to be finding out about something for the first time.
Since the late 1990s there have been at least 12 major reviews, vision statement and Green/White Papers – and we’ve failed to implement the funding recommendations of any of them. Despite Boris Johnson’s claim to have a plan for social care when he became Prime Minister in 2019, and despite all the recent debate around funding models, it’s hard to imagine that this might be 13th time lucky. While the devil is in the detail, many people feel that an increase in National Insurance is much less equitable than funding social care from general taxation, disproportionately affecting younger people and those on low incomes. It’s also possible that any cap could be set at too high a level to make much difference, preventing people from preparing for future care costs because the sums involved are simply too large to contemplate. What emerges might also be a health and social care fund, focusing initially on the NHS backlog following COVID, before any new money gets anywhere near social care.
However, while even a limited cap might have some positive impact, this still seems a major case of putting the cart before the horse. A cap is a start and would help to at least soften one of the worst and most cruel cliff edges in our welfare system. However, by itself, all it would do is change who pays: it wouldn’t necessarily mean that even an extra penny was available to spend on more or better care or to improve the terms and conditions of low-paid, exhausted and demoralised workers. Even worse, it would do nothing to change the nature of current services – so all we’d have is a row about who pays, and potentially no discussion of what we want social care to help us achieve in our lives, what principles it should be based on and how future care should be organised and delivered. Fortunately there are excellent attempts to do just this – from Social Care Future and the Alzheimer’s Society, to the ‘community conversations’ facilitated by Engage Britain or the forthcoming Archbishop’s Commission on Reimaging Care.
Although very different in their nature and origins, all these initiatives seem likely to point in a similar direction. As an example, I’m the Director of IMPACT (‘Improving Adult Care Together’), a new UK centre for implementing evidence in adult social care, and we see social care not as a basic safety net that we have to provide to meet minimum public expectations, but as a form of social and economic investment that helps us to be full citizens, live chosen lifestyles and have a better life together as a society. Our strapline (suggested by someone who draws on care and support themselves) is that “good care isn’t just about ‘services’, it’s about having a life”. This has much in common with the vision developed by Social Care Future: “we all want to live in the place we call home with the people and things that we love, in communities where we look out for one another, doing the things that matter to us.” Unfortunately, the current debate about social care funding seems about as far away as one can get from these visions for people’s lives – and it’s hard not feel an exhausting sense of déjà vu at what could be yet another major missed opportunity.
Jon Glasby is Professor of Health and Social Care at the University of Birmingham, and Director of IMPACT, the UK centre for implementing evidence in adult social care.
Our previous work on the nature and costs of social care reform is published in the Journal of Social Policy, setting out different spending scenarios depending on the level of reform that is pursued, and identifying a ‘lost decade’ between 2010 and 2020 when social care reform arguable stalled, and in many ways went backwards.
Are you involved in adult social care? IMPACT, a new UK centre for implementing evidence in adult social care, want to hear from you. The Centre are particularly interested in hearing from: people who use care and support services, user-led and community organisations, groups that work with people whose voices are seldom heard, people who look after someone else – ‘carers’, people who work in social care and people from black and minority ethnic communities.
Easy read version.