The Sunday long read
We all die, and before we do, most of us will need some care. So do many disabled people. But because we don’t like to think about these issues, there is little pressure on politicians to make sure that care is there, and working well. It is only when we have a friend or relative in need, or need care ourselves, that we discover how poor and disorganised the services are.
So, although politicians regularly promise reform, they shy away from the costs, or indeed any action beyond commissioning the reports which gather dust on shelves in Whitehall. And new money for “health and social care” almost always turns out to mean more money for health now, and perhaps for care later. Until it hits us personally, we prefer the cheerful investment in the health service, which is about making people better, rather than care, which most people associate with getting worse.
A history of inaction
In 2009, the Labour Party announced that it would create a National Care Service, but there was little detail, and the plan died when they lost the election.
In typical style, Boris Johnson announced that he had an “oven ready” plan for social care. But after much delay, this turned out to be only a change in the politically sensitive issue of old people selling their houses to pay for care. It did nothing to tackle the problems of staffing, pay or entitlement to care. And in the event implementation was deferred beyond the life of that government.
In 2022 the Parliamentary Committee for Levelling up, Housing and Communities said that
The adult social care sector does not have enough funding either in the here and now, or in the longer-term. The Government’s approach is little more than a vision, with no roadmap, no timetable, no milestones, and no measures of success.
This summer, the Committee Chair wrote to the minister to raise concerns about the government’s response.
Preparing for government
In an attempt to avoid falling into the same trap, the Fabian Society has been working to flesh out the idea of a National Care Service, in the hope that an incoming Labour government would be able to move rapidly after an election.
Last month, they submitted their proposals to Wes Streeting, the Shadow Secretary of State for Health and Social Care. The 64 page report “Support guaranteed: the roadmap to a national care service” maps out in some detail how such a service might be organised, and how it could be created.
They highlight the dire state of the current service. At a time when an ageing population is increasing demand, spending has been cut drastically. Necessary care is being rationed: a quarter of a million people are waiting for an assessment of their care needs and 1.5 million people are not receiving the care they need. With shrinking budgets and 165,000 vacant posts, some private care providers are struggling to survive, and some are closing down. The Parliamentary Committee recommended that the Government “urgently needs to allocate more funding to adult social care, in the order of several billions each year, at least £7 billion.”
A plan which can pay for itself
There is a clear moral case that government should guarantee the health, wellbeing and safety of dependent people. But this must be paid for, so the report explores the business case. There are potentially huge benefits to the NHS budget and its waiting lists. Although a night in hospital typically costs four times as much as a night in residential care, there are currently 13,000 medically fit people occupying hospital beds for lack of social care outside. Furthermore, a £1 billion increase in taxes (0.1% of tax revenue) to improve social care would create 50,000 jobs, and inject money into local economies, especially in the most disadvantaged areas. So there is scope financially to implement change.
The plan’s first priority would be to stabilise the service, with an immediate one year “rescue plan”. This would aim to avoid the loss of more facilities, and stop the implosion of the workforce.
Then there would be wide consultation on what services are actually needed and preferred, followed by a National Care Service Act which would define citizens’ rights to receive care, and the responsibilities of the public sector. Only then would the system of charging be reformed.
The shape of the service
At present, responsibility for social care lies with Local Authorities. Faced with severe cuts to their budgets, they have had to cut other services to maintain their statutory responsibility for social care, and three have already gone bankrupt.
By contrast, responsibility for the new service would be national, with the Minister working in partnership with properly resourced local authorities. There would be long term planning, including of finances, to secure sustainability, and provide confidence to enable providers to invest in new facilities.
The report makes 48 recommendations that would result in a transformation in adult care in England. The key elements of the proposals include:
- “For everyone: support will be available to everyone, regardless of their means, and at an earlier stage as their care and support needs develop. Disabled people and unpaid carers will be automatically referred to the service. Everyone will have peace of mind about help being there for them in the future.
- Stronger rights: citizen rights will be spelled out in a co-produced National Care Service constitution and people will have control and choice over the support they get. Disabled and older people will have a new right to choose where they live and to take part in society. Unpaid carers will be asked how much they wish to care and will have a new right to short breaks. A formal appeal process will be introduced.
- A new public service: the National Care Service will offer end-to-end support under a shared brand delivered together by national government, local councils and licensed care providers. Independent providers will be fairly funded but expected to operate as part of a public service with new standards on care quality, workforce and financial conduct. National leadership and consistency will replace postcode lotteries.
- A fair workforce settlement: a sector-wide Fair Pay Agreement will be negotiated including a sector minimum wage and minimum employment conditions. People employed by contracted National Care Service providers will have national pay-bands and employment terms designed to achieve parity over time with similar roles in the NHS.
- More affordable charges: reforms to care funding should run in parallel to other changes, so that support becomes more affordable over time as services start to improve. Incoming ministers should match any government funding reforms announced before the next election. As they develop the new service, they should also consider other options, like making support free for people with lifelong disabilities.”
How to pay for this?
The proposals are detailed, but modest, recognising that an incoming Labour government will face many urgent priorities, without a lot of money to spend. In keeping with Fabian tradition, they are designed to be realistic and progressive, rather than revolutionary. This reduces the chance of the plan being rejected out of hand, but runs the risk that only the first step ever gets done.
The report focuses first on stabilising the existing system, ensuring consistency of funding and service levels across the country, and planning for gradual improvement over 10 years.
It identifies a range of funding issues which a government needs to consider. They include a National Care Service Investment Fund, to support the creation of new facilities and draw in private finance; implementing the agreed charging reforms; a review of means testing thresholds; reforms to means testing; and introducing a “modest” universal contribution; a lifetime cap on care costs; and a review of the relationship between care financing and the social security system.
Stopping the rot
Despite the similarity of names, the creation of a National Care Service will never be like the creation of the NHS in 1948. The NHS affected everybody from day one, and was seen as a great national achievement. The present state of the care “system” is as inadequate and unequal as health was in 1947, but it is experienced only by a few people at any one time. When polls ask what issues people want government to fix, nobody mentions social care.
So change can only come gradually. This is a carefully thought through set of proposals which would lead, over time, to a much more defensible service, which almost all of us would benefit from. The full report provides a lot of detail of how this might be achieved.
But, like some other policy challenges, it depends on long term planning and commitments, which are difficult to secure in our parliamentary system, which rewards short term political advantage over long term consistency.
But in the short term it could stop the rot. In our present circumstances that would itself be an achievement.
The Fabian Society was one of the founders of the Labour Party. It was created to advance the principles of social democracy and democratic socialism via gradual reform in democracies, rather than by revolutionary overthrow. Its 7,000 members include Keir Starmer and 13 other Shadow Ministers.