By Professor Catherine Needham, Professor of Public Policy and Public Management, Health Services Management Centre, University of Birmingham
The National Assistance Act (1948) reaches its 75th anniversary, and with much less fanfare than the 75th anniversary of the NHS. Social care for working age disabled people, older people and those with long-term mental health conditions was separated out from healthcare in 1948. It was allocated to local government rather than national government, and was means-tested rather than free at the point of use.
75 years on, a lot of the issues created at that foundational moment are still with us. Efforts to integrate health and care over recent decades have been disappointing and it remains very much unfinished business.
What’s changed?
A lot has changed since 1948. We now have four distinct health and care systems in the four nations of the UK. From the common root of the National Assistance Act, each has now developed something quite different. In research for our book on Social Care in the UK’s Four Nations we looked at reforms in the period since the devolution settlements of the late 1990s. We found that Scotland had been the most active in its social care legislation, with key interventions including the introduction of free personal care and improved benefits for unpaid carers. Wales and Northern Ireland had less agenda capacity due to constitutional issues, although Wales has made changes such as making the means test more generous than it is elsewhere in the UK. England has attempted a number of reforms which have been poorly implemented or abandoned. The delayed implementation of the cap on care spending – which would have limited individual liability for high care costs for the first time – is a signal that reform continues to be ‘jam tomorrow’.
One of the big changes of recent years has been the impact of the Covid-19 pandemic. The pandemic had a devastating impact on people using and working in long-term care, both in the UK and globally. In the UK, the pandemic revealed how key decision makers did not understand the social care context, and how key equipment such as tests and personal protective equipment failed to get where it was needed. The profile of social care increased during the pandemic, and the language of ‘Build Back Better’ created some optimism that social care might come out from under the shadow of the NHS and be made more sustainable. However, government promises around improved funding have been watered down and – in England at least – reform measures have stalled.
In Scotland and Wales, there is more momentum around reform, and both nations are proposing versions of a National Care Service to improve the profile and effectiveness of social care. Last month also saw proposals from the Fabian Society for a National Care Service for England, which is likely to have some influence on Labour Party care policy going into next year’s general election.
Each of these iterations of a National Care Service are different – in Scotland, for example, the proposals include taking responsibility for social care away from local government. This has a number of potential implications which we are exploring in a project with the Local Government Information Unit as part of our work for the ESRC Centre for Care. None of the proposed National Care Services can really claim to be providing for social care what the NHS provided for health 75 years ago. It’s not nationalised provision, the means test will remain (with variations) in all parts of the UK. No one has a clear account of how the vital investment will come into the sector, following the reversal of the health and social care levy on National Insurance last year.
What stays the same?
I wrote a blog about the 70 year anniversary of the Act. Some things have changed since then – with the Covid-19 pandemic having the most dramatic impact. But a lot has stayed the same. Poverty, exclusion and abuse of disabled people continue to be tolerated. The lives of disabled people, disproportionately affected by poverty, have got harder during the cost of living crisis. Abuse in institutional settings continues and people are still getting stuck in those settings. However, there are counter-trends. There is more co-production of policy and research than ever before, and in some places – like Hammersmith and Fulham – this has led to real change.
What might I write in the blog for the 80th anniversary of the National Assistance Act? In another five years, it is possible that we might have National Care Services in three of the UK’s nations, and some version of reform in Northern Ireland. With greater investment, there might be less unmet need and better terms and conditions for staff. But we need the imagination to think beyond this. We need to aspire to social care which is for us, not a marginalised them over there who are too easy to ignore.
In the work we are doing for the Centre for Care, we are looking at how to do this at a system level as well as how we might recognise and support the changes that are important to people. Too often people talk about being stuck, with a ‘flourishing life’ remaining well out of reach. Living a good life with disability and frailty needs to be recognised as all of our business, just as we all have a vested interest in an effective and sustainable NHS.
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The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of the University of Birmingham.