The sense of disappointment bordering on despair about the autumn statement’s silence on social care is palpable throughout local government and the social care sector. The chorus of support for action was impressive and unprecedented, unifying many politicians of all parties, NHS leaders, royal medical colleges, the health select committee, independent thinktanks and the Care Quality Commission, as well as those who might be regarded as the “usual suspects”.
Calm and careful reflection is now needed as to why such a formidable and authoritative range of opinion was so comprehensively disregarded. Simply re-stating the case for better funding is not enough. What would it take for the government to act? Where do we go from here? What do we need to do differently?
One view is that we need to make a stronger evidence-based case for social care as an investment producing wider benefits to the economy, rather than a cost. This would be rooted in a different vision of care provision that promotes independence and community resilience instead of creating dependence on formal services. But is lack of evidence the real reason for government inaction?
The need for action was recognised as long ago as 1997, when Tony Blair established a royal commission. The case for adequate funding was taken up again a decade ago by the late Derek Wanless in meticulous and compelling detail – 344 pages and 16 supporting research papers. The Dilnot Commission in 2011 added further analysis, as did the Barker Commission three years later. These three reviews were led not by professional lobbyists or provider interests but a trio of hard-nosed bankers and economists. So the proposition that the Treasury stands ready with the chequebook if only we could provide even more, or different, evidence is fanciful. There are deeper underlying reasons why this government, like its predecessors, has failed to grasp the nettle.
The most obvious is the historical legacy of means testing for social care, established in 1948, alongside a later policy shift away from long-term care provided free by the NHS. As society has grown richer, many people now have savings and assets that exceed the means test threshold of £23,250. This has allowed successive governments to stand by and watch as the costs of care fall increasingly on private individuals rather than the public purse. Over half of care home fees are now met by individuals, not the state. Persuading the Treasury to spend more when there is already a covert and convenient way of raising money through, in effect, a form of self-insurance, will always be a tough ask. Dilnot-inspired plansfor a cap on very high costs were a foot in the door, but it was firmly shut again with the postponement of those reforms until 2020 (and only ministers appear to think they will see the light of day).
Another explanation for inaction is that, unlike the NHS, social care is poorly understood by the general public and does not resonate as a significant electoral issue in MPs’ postbags and surgeries. A troubled NHS easily commands public attention through visual images of overflowing hospitals and queuing ambulances. But when the social care system is “full” few notice, the consequences scattered silently and invisibly across thousands of homes and families. It makes little noise on the radar of political and public concern.
Allied to this are 6 million other reasons that have allowed governments to get away with underfunding social care – unpaid carers, the natural shock absorberswho so far have cushioned the NHS and social care system from the full impact of inadequate services. For all the policy rhetoric about supporting carers, there is a tacit assumption that care should be undertaken by families – usually wives and daughters – and that, again unlike the NHS, it does not require highly skilled and well-resourced public provision.
So it is unlikely that more or better evidence alone will generate the necessary public support and political will for change. The case for a social movement that generates bottom-up pressure for action looks set to gather momentum. The social care sector will need to seize the opportunities offered by social media with considerably more enthusiasm than it has shown to date. It might also need to replace the nebulous and woolly term “social care” with a different vocabulary that unifies and resonates more clearly with the diverse range of individuals of all ages and circumstances with care and support needs.
Creating the conditions in which a social movement can emerge and flourish will take time. Unless the government has a change of heart, more of us will have to get used to the idea that we are responsible for paying for our own care unless we are relatively poor and have very high needs. Unpalatable a prospect though that might be, the time has come for a sensible discussion about how we should be supported to do that through better advice and information, and the use of the tax, benefits and pension systems.
In the meantime pressures on health and social care will not go away. Unpaid carers can absorb only so many bumps in the road; prospects for the NHS with winter almost upon us are grim. The possibility of large-scale provider failures that imperil the care of hundreds or even thousands of people is an ever-present possibility. The government is taking big risks on all of these fronts as a direct consequence of its indifference. How big a price, in human as well as financial terms, it is prepared to pay remains to be seen.
Nearest tube – Elephant & Castle underground station (Northern and Bakerloo lines).
Nearest Railway Station – Elephant & Castle
Buses from Elephant and Castle – ask bus driver for Burgess Park. Bus numbers: 12, 171, 148, 176, 68, 484, 42, 40, 45