Here we go again: Will social care be fixed at last?
OPINION & ANALYSIS: QT columnist Bob Hudson, Visiting Professor in Public Policy at Sunderland University, takes a look at the question of social care reform and gives you a starter for 10
Here we go again, back to the future in adult social care. Take your pick of any prime minister over the last 30 years and the pledges run deep.
In 1997, Tony Blair proclaimed: “I don’t want our children brought up in a country where the only way pensioners can get long-term care is by selling their home.” Nothing happened.
In 2019, Boris Johnson boasted: “We will fix the crisis in social care once and for all with a clear plan we have prepared to give every older person the dignity and security they deserve.” There was no such plan. Nothing happened.
Now it’s the turn of Health and Social Care Secretary Wes Streeting, who has assured us that: “This government is determined to grip the crisis in social care, which is historic and has been decades in the making.”
To show he means business, the Department of Health & Social Care has issued this press release laying out its intentions to ‘transform social care’
The release contains some worthy minutiae that has received little public attention: an £86 million boost to the Disabled Facilities Grant; training care workers to take blood pressure checks; developing a shared digital platform between the NHS and care staff (something much easier said than done); and ‘harnessing the power of care technology’ (ditto).
Nor should it be forgotten that the Government is passing legislation on fair pay agreements for care workers and raising the carers allowance threshold.
‘It’s like the Titanic having a meeting after it’s hit the iceberg to work out how to stop it sinking while it’s sinking.’
However, it is the proposal to set up an independent commission led by Baroness Louise Casey that has attracted most attention, not all of it favourable. This is not a criticism of the Baroness herself, who is (somewhat unctuously) described in the press release as ‘Whitehall’s greatest do-er.’
Rather the problem is the time-scale: a first phase report in 2026 identifying the critical issues and a second report in 2028 making longer-term recommendations.
The backlash has been fierce and across the board. The Daily Express – conveniently forgetting who had been running the country for the past 14 years – thundered ‘It’s a Cop-Out on Social Care Reforms!’ Sarah Woolnough, CEO of the respected King’s Fund think tank condemned the timescale as ‘far too long.’ Mike Padgham, Chair of the Independent Care Group quipped: ‘It’s like the Titanic having a meeting after it’s hit the iceberg to work out how to stop it sinking while it’s sinking.’
Even the cartoonists in the relatively friendly Guardian and Observer have been having a field day, mocking Streeting as an inhabitant of long grass. All of this bears testimony to Harold Wilson’s dictum on royal commissions that ‘take minutes and waste years’ – and he would know, having set up 10 of them during his stints as prime minister.
Of course, no one doubts that the redoubtable Baroness will do a thorough job and deliver a creditable report. The concern is that it has all been done before – since 1997, social care has been the subject of three government commissions, three independent commissions, five white papers, and 14 parliamentary committee inquiries.
Many will wonder what new can be learned after all of this, and why it would take three years to divine the messages. Indeed, Jane Townson, CEO of the Home Care Association, tartly observed that the Baroness should simply ask ChatGPT to synthesise all existing evidence – that might take three minutes rather than three years.
What these many investigations have revealed is a familiar list of problems – here is your starter for ten:
Lack of Funding: local councils have suffered spending cuts of close to 50% since 2010; they simply do not have the money to commission better services; meanwhile thresholds for accessing support grow ever tighter.
Unmet Need: Age UK estimates there are about two million people in England with unmet care needs; making inroads into this backlog needs to be treated with the same urgency as addressing NHS waiting lists.
Unsupported Carers: Carers UK estimate there could be just over 10 million people in the UK providing unpaid - and typically unsupported - care. They need help.
Workforce Recruitment and Retention: Skills for Care identifies problems of both recruitment and retention in a badly paid workforce lacking a career structure – there are currently 131,000 vacancies.
Uncapped Care Costs: The 2011 Dilnot Commission plan for a cap on individual care costs has never been taken up, despite making it onto the statute book; and social care isn’t just about older people, it also covers working age adults with high-cost care packages.
Weak Regulation: Inspection levels are well below pre-Covid volumes and there is a lack of expertise amongst inspectors, as well as inconsistency in assessments. Wes Streeting has described the Care Quality Commission as ‘not fit for purpose.’
Lack of Integration with the NHS: the unavailability of social care provision is routinely identified as a reason for delayed hospital discharges; they constitute two very different operating models with no real prospect of harmonising them.
Shifting Responsibilities from the NHS to Social Care: there are inter-agency battlegrounds over rehabilitation and long-term care, especially dementia; accessing Continuing Health Care, paid for by the NHS, is a Kafkaesque experience.
Outsourcing Public Services: public provision of social care has largely disappeared; small operators (commercial and not-for-profit) can barely function; bigger ones find ways of profiteering; the market is devoid of overview, supervision, and planning.
Failing to Listen to Users and Carers: Social care is fundamentally about rights and relationships – helping people to pursue the things that matter most to them, irrespective of their age or conditions. This has tended to take second place to tick-box assessment processes.
Putting these problems right requires beginning to tackle each of them in turn, and in fairness a start has already been made on numbers 3 and 4 on the above list. This leaves much more to be done, but piecemeal problem-tackling alone is insufficient.
If a social democratic government with a majority of 172 won’t take the lead and fix social care, who will?
Any serious strategy must be underpinned by a shared vision on the purpose of social care - function determines form. Surely the answer lies in a service that meets the expressed needs of those who use it, rather than being used as a sticking plaster for the problems of the NHS, or as a cash-cow for hedge-fund chancers.
As several commentators have pointed out, this requires political leadership. Andy Burnham, the Mayor of Greater Manchester, has rightly said: “‘It’s been political cowardice rather than complexity that has prevented a solution all these years.” The Health Secretary’s insistence on searching for an unlikely all-party consensus by 2028 bears the hallmarks of yet more political cowardice.
Some ask, if a social democratic government with a majority of 172 won’t take the lead and fix social care, who will? It’s a fair question, but one that could equally be asked of a host of other festering problems, including child poverty, the housing shortage, climate change and much more.
As the saying goes, ‘to govern is to choose’, and social care has been waiting to be chosen for over 30 years.
Professor Hudson is author of Clients, Consumers or Citizens?: The Privatisation of Adult Social Care in England which was published in 2021.
Good overview of *all* the challenges facing any plan for social care provision.
The fundamental lack of funding won’t go away until a government manages to convince the electorate that we need to raise more taxes - they could make a start with inheritance tax, drastically lowering the threshold for it, taking more for estates which include property, and tackling the general unfairness of inherited wealth more robustly.