Social care reform – Always Jam Tomorrow

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By Professor Catherine Needham, Professor of Public Policy and Public Management
Health Services Management Centre, University of Birmingham

“When reform comes I hope it will start with how to build full and meaningful lives for people who receive care, and not just be about the demographic time-bomb and how to stop people selling their homes for care.”

The notion of ‘jam tomorrow…but never jam today’ (found in Alice through the Looking Glass) captures the state of permanent anticipation in which the social care system is poised. Politicians from Tony Blair onwards have offered to put it on a more secure financial footing, recognising that a system created in 1948 can no longer meet the level and types of demand placed upon it. Progress has been almost non-existent.

Simon Stevens, the Chief Executive of the NHS, was on the BBC on Sunday, insisting that social care funding must be reformed in the next year. He is one of many voices that have positioned the Covid-19 pandemic as a turning point. The scale of the Covid-related deaths in care homes is so huge that there is an implicit assumption that it must be the catalyst we have been waiting for to unstick reform. Equally vociferous in recent calls for reform has been former Secretary of State for Health and Social Care, Jeremy Hunt. Covid-19 has been a turning point – a ‘never again’ moment.

Unlike these leaders (who themselves managed to achieve little momentum on social care reform prior to the pandemic), I am sceptical that this is the right kind of turning point. Already Matt Hancock, the Heath and Social Care Secretary, has said that Covid-19 will delay reform further. There remains no clear plan about what reform will be, and Boris Johnson’s call for a cross party consensus is hard to imagine in these fractious times. Social care needs more money, now and over the long term. That will have to be raised somehow, but cries of a ‘death tax’ and ‘dementia tax’ have accompanied previous attempts to set out a plan for this, and it remains politically toxic. Just as complex is working out how to get the health and social care system to work closer together – with the lack of linkage being seen as one of the causes of the high levels of care home deaths. Many people are now calling for a National Care System, which properly integrates health and social care – although as Sally Warren from the Kings Fund has emphasised – it’s unclear what a National Care System means and why it would help. Moves to make social care more like the NHS, or to merge the two, could threaten the progress that has been made in making care about people’s lives not their impairments, supporting the ‘whole person’ .

All this is not to say that Covid-19 has not been a turning point. It’s hard to take stock of the lasting impact of a crisis whilst living through it, but two things at least will not be the same in the future:

  • First, the differences between the four nations of the UK have been drawn more sharply than ever before. Perceived failings at Westminster have led leaders in the other jurisdictions to further distance themselves from a UK-wide approach to social care. This is likely to exacerbate existing differences – in charging policies, the role of markets and private providers, and how the NHS and adult social care connect.  The future social care funding settlement, if it ever comes, will look different in each of the four nations. Our research on Care in the Four Nations is looking more at this, as part of the ESRC Sustainable Care programme.
  • Second, the professional and public trust vital for care reform will be harder to find than it was before the pandemic. You can’t have a new reform settlement for social care without trust between different parts of the system, and between the state and the public. Relationships have worsened between government and care providers over access to PPE and testing. People with disabilities were outraged by suggestions that they were not a priority for ventilators. Some older people have felt patronised and discriminated against by risk-based age profiling.

Reform of social care remains vital and, despite my scepticism, I hope that Simon Stevens is right about jam today. When reform comes I hope it will start with how to build full and meaningful lives for people who receive care, and not just be about the demographic time-bomb and how to stop people selling their homes for care. There are other ways forward – the Social Care Future movement suggests ‘start with the people, talk about lives, relationships and love, and build up from there. If Covid-19 has done anything positive it is in reminding us that those are the things that matter.

A longer version of this blog about ‘Thinking beyond the crisis’, in conversation with others, is available here.

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