The crisis in social care: what can the UK do?
Locked down for a second time before winter has begun, and with no reason to expect that we won’t be locked down again before it has ended, it is easy to forget that COVID-19 is a problem that has only been with us for a few months. Promising news about a vaccine suggests that it may only be a few months more before it is overcome. Whenever this happens, however, we will still be left with all those problems that have remained unsolved not just for months or years but for decades.
In this blog, the third of three from past and current members of Enfield Council, former council leader Doug Taylor, writing in a personal capacity, identifies improving social care as perhaps the most intractable – and therefore the most depressing – of them all.
What makes social care so hard is that it is a problem with three separate strands to it. The first is how it is funded and paid for. The second is how social care is delivered and by whom. The third is what we want social care to provide, both where, when and how. Recognising that there are three strands to the social care question is crucial. Looking back, this explains why it has been so hard to resolve compared (say) with pensions, which has only two strands to it. Looking forward, it explains why solutions which focus on just one strand (say, who is responsible for delivery), are doomed to failure because they are incomplete.
Fundamental improvements to the provision of social care will bring no glittering prizes but the benefits they will bring will endure long after COVID joins SARS and Spanish Flu in the history books.
Funding or organisation – or funding and organisation?
Is how we fund social care the most depressing and intractable question now facing us? Some argue for reorganising the structures through which social care is commissioned and delivered. By giving social care more status and creating a more holistic and integrated relationship between health and social care, this could be a way to create a better system.
Without resolving the funding conundrum, however, restructuring won’t be enough. Put bluntly, the scale of the financing needed to create an integrated service free to all at the point of delivery, is not solved in itself by integrating primary care, acute services, public health and local social care services.
Can the public purse in the impending economic crisis pay for universal high-quality care? The appetite for better services is easy to understand, but the economics of funding in a period of budget constraint means that simply saying spend more on care now may be too hard to deliver.
Besides funding and structure, citizen acceptance is critical too. Future electoral impact is always important for any government; unpopular decisions with little immediate return are normally very hard to take. But these are not normal times. Governments in parliamentary democracies sometimes need emergencies to make long term bold policy. We may have that opportunity now.
Funding: a sticking plaster response to a fundamental problem
In care homes we see increased cross subsidy to local authority clients from self-funders. This is a fundamental part of the sticking plaster over the wound of state underfunding. Although precepts for adult social care have eased the financial squeeze on local authorities a little, that is after years of austerity. Councils cannot solve the financial conundrum themselves. They must also resist any turf war that could be created between various stakeholders as to who has the legitimacy to determine and deliver services.
A further funding question is that if COVID-19 really is a game changer, operating with low wage care staff cannot continue. This will add significantly to the overall costs of the system as fairer pay and benefits will need to be mandatory, and will dramatically increase overall labour costs.
The pandemic has shown social care to be the Cinderella of public service, but any hope that this might be the catalyst for change must reckon with unfavourable demographic trends, as more and more older people live longer, many with chronic long-term health conditions.
Principles for care
Now is the time to answer the fundamental questions about the societal vision for care and how it ensures compassionate ageing. To link it to a radical redesign of all healthcare may be a bridge too far to resolve in short order. Care provided as if part of the NHS has attractions, but even strong advocates like Andy Burnham concede that older citizens will have to pay to finance the system at least in the short term.
Does the structure of care provision really matter? Yes. I start from the premise that there can be no solution to care unless the interdependency of healthcare, social care and other community services are restructured in the interests of the citizen as client. Here are three principles which I believe should guide the way we change the care system.
First, put the resident at the centre of the system backed up with a national charter of rights about access, quality and security.
Second, improve health outcomes generally and narrow health inequalities. This in turn requires guaranteeing access to good quality care wherever we live and irrespective of wealth.
Third, prioritise prevention, early intervention and community services. Key to this is treating home as the core of care. Whoever leads, holistic design of a system including all agencies is essential.
Funding and the lessons from pension reform
Funding will be at the heart of a healthy system. Its intractability is not unconnected to the fact that adequacy requires a funding injection either from the state, via taxation increases, or directly from individuals via private insurance or asset decumulation. None of this is likely itself to be popular, and maybe a vote loser, as Teresa May discovered. To be serious about solving the problems within the care sector, a primary question is, what is the balance between collective and individual payments? One way or another, the public will pay, if not through a tax on earnings, then a tax on wealth such as on property or, a mandated insurance product, or through fees and charges.
A similar funding problem existed in pension provision but cross-party consensus on the solution created a way forward. A Pensions Commission was established under the chairmanship of Adair Turner which laid out four solutions, namely: accept future pensioner poverty as a consequence of an ageing society; increase general taxation to pay higher pensions; ask people to work longer and commence State Pension payments later in life, matching increased life expectancy; require increased personal pension saving.
The Commission promoted the third and fourth options which became government policy with opposition buy in. Although imperfect in transitioning for women at retirement age, and raising questions about longer working age for manual employment, the consensus remains largely in place. In that light, the State Pension age was raised over time thus delaying payments from the State to pensioners, and the Government introduced, for most workers without employer sponsored pension schemes, a statutory need to provide a scheme and automatically enrol employees into it, with an employer financial contribution. Although incomplete (missing out, for example, the self-employed and low paid workers with multiple employers), the settlement did strike the balance between state and individual responsibility to plan for retirement.
There are certainly differences between problems with pensions and social care but also similarities, and in the post COVID-19 world the opportunity should be taken to craft a funding arrangement for social care can take lessons from the pensions example.
The analogy struggles when it comes to the adequacy of provision. In care, this is driven by a centralised view which shapes eligibility criteria, as well as a consumer view largely driven by personal wealth which shapes attitudes and behaviour – and responses in turn to government proposals on financing. In pensions, it is often a question addressed only by an individual at or near retirement. The tripartite mixed model of structure via State pension, workplace pension and personal pensions is largely accepted. The balance between State and private provision in social care is not resolved.
Past attempts to solve the problem
There have been a number of attempts to address this question. In 1999, a Royal Commission proposed a shift to state funding which was rejected by the Government, although partially adopted in Scotland. Two reviews in 2006 – by the Kings Fund and Joseph Rowntree Foundation – pointed out that the current system was unsustainable.
Teresa May, for the Conservative party manifesto in May 2017, offered what was described by its opponents as a dementia tax. Under these proposals, part of the initial Conservative Party election manifesto, care at home would be paid out of personal assets until that was denuded to £100,000. In addition, the sale of a house as an asset would be protected until death.
Boris Johnson, in the absence of a Government Green Paper, has decided he needs a cross-party approach to create a plan that works or possibly to create political cover for difficult decisions. It was the need for consensus that scuppered previous Labour plans in 2010 when there was a collapse of cross-party talks prior to the general election. Labour planned a Care Commission to improve home and residential care, free residential care after two years in residential care, and a National Care Service to establish the funding source.
Later, Sir Andrew Dilnot was Chair of the Commission on the Funding of Care and Support and his proposal was that there would be a cap on care costs paid by the individual of £72,000. At a stroke, mandatory liability was limited but the individual could spend more on extras if that was their choice and they could afford it. Despite still being in the in-tray it has not been implemented.
As a society, since the 1945 creation of the Welfare State, we had assumptions on improving living conditions, with each generation doing better than the last generation. Not only in terms of personal wealth and possessions, but also investment in the public realm, health, and the fabric of our communities. This has been under challenge recently and post-2010 austerity has stripped away public provision, and has especially denuded local councils. COVID-19 is creating massive public debt, ushering in a recession which puts a question mark about future national wealth. It raises the spectre of taxpayers currently aged 30 to 60 bearing most of the burden for restyling the new care system, while richer pensioners having also seen huge housing asset appreciation being the beneficiaries of investment by the state in social care. This is at the heart of future intergenerational fairness.
While the Turner Commission found a key to unlock the pensions problem, successive attempts with social care have failed. As a result, we now have disenchanted staff, angry children of parents needing care, rationing of homecare services, and small care homes at risk of collapse. A sector as important as primary and acute health provision has been exposed during the pandemic as a second-class part of how we look after our citizens.
If there is an exam question that must be resolved, it is how to deliver the fair and secure protection against ageing and disabilities which need to be defined by society, and through consensual funding sources that are fair to all generations, and are sustainable financially and politically. In doing that we will need to not only draw boundaries of personal versus state responsibility but also what role, if any, the private sector should have in delivery.