Economist and former national statistics chief Andrew Dilnot tells a story about the myth of a golden age when grandma was looked after in the bosom of her family, sitting by the inglenook fireplace knitting socks for her grandchildren. It was a myth, he explains, because grandma didn’t exist – grandma was dead.
It’s a story that encapsulates the sweeping changes engulfing society since the end of World War II and why social care is now one of the pressing public policy challenges of our generation. Back in the 1940s, not that many people lived long enough to need care, and those who did were poor enough to get it free. Mostly, this was institutional care in former workhouse buildings and long-stay hospital wards. Few people had homes to sell. Instead, universal health care was the big priority. Alongside the popular acclaim for the newly created NHS – the poster-boy of the welfare state – the opening words of the parallel legislation for ‘welfare’ services, the National Assistance Act, said it all: ‘an Act to eliminate the Poor Law’.
Seventy-four years later, our population is much bigger, we are living longer and many of us experience chronic long-term health problems that, thanks to the success of modern medicine, we will live with, not die from. As a result, most of us will need some degree of care and support at some point in our lives, usually, but not always in our later years (needs are growing fastest among the under 65s). We are generally much better off and many of us enjoy wealth that puts financial help from the state out of reach because, unlike health care, social care is not free at the point of use.
Unlike other big policy challenges like climate change, sustainable energy, crime, poverty and inequality, the crisis of social care is born of success, not failure. Yet successive governments have failed to address the consequences of the rapid march of social and economic progress. Today, England is paying a heavy price for decades of policy neglect with over 500,000 people now waiting for social care.
Whereas NHS treatment and spending has expanded over the years, reflecting increasing needs and a bigger population, the trends in social care have been demography-defying. Fewer people are receiving support than a decade ago and real-terms spending has fallen, despite recent short-term cash injections. Staff vacancy rates have reached a record high of 165,000. By a process of administrative accident, over 90 per cent of care is delivered through private bodies, creating new concerns about accountability and quality. Crucially, the social care system seems to have forgotten its primary purpose of helping people to live better lives, with people using the language of military conflict to describe their experience of seeking support and the reduction of care to basic ‘life and limb’ functions at the expense of quality of life.
As the crisis in social care deepens, another report, review or white paper will be no more successful than its many predecessors. Instead, a different road to reform is needed to secure political traction and public support for change. This would involve replacing a traditional, top-down policy-making approach with a different process using coproduction, deliberative democracy, consensus-building and drawing on new thinking about long-term policy making.
Echoing Joseph Overton, the goal of reformers should not be to lobby politicians to support unpopular or unfamiliar policies but rather to convince voters that policies for good social care are ones they can value and support. The predominant mindset that views care as a cost, a financial burden or a politically toxic problem that is just too difficult should be replaced by a recognition that all advanced countries depend on good social care as part of their economic and social infrastructure, in the same way that they depend on investment in education, skills and health care. As American campaigner Ai-jen Poo describes it, care work is the work that makes all other work possible.
On this positive foundation we can assemble three new building blocks for better care:
- A new social ‘contract for care’ that sets out the mutual roles and responsibilities of individuals, families, communities and central and local government.
- A different model of design and delivery that gives people new rights and resources based on entitlement not professional discretion, including a new deal for people who provide care and support, both paid and unpaid; there is a wealth of locally generated ideas and innovations that can be drawn upon to give people new choices and options about their care and support;
- A new funding settlement that positions social care as a major public service in its own right, on a par with other universal services such as education and health care.
The new political mood music favouring a smaller state, lower taxes and deregulation does not encourage optimism about the appetite of the Sunak government for embracing a new road to social care reform. Yet we should not allow the dreadful economic and fiscal climate to extinguish hope that fundamental change is possible, as the post-war welfare state testifies. If anything, recent events strengthen the case for social care investment as an integral feature of economic and social reconstruction and recovery.
Richard Humphries has worked in social care for 45 years in various roles including as a social worker, director of Social Services and – for 11 years – as Senior Fellow at The King’s Fund. He is a Senior Policy Advisor at the Health Foundation and Visiting Professor at the University of Worcester. @richardnotatkf
Ending the Social Care Crisis by Richard Humphries is available on the Bristol University Press website. Order here for £14.99.
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