Falling flat – the care crisis continues

Social care folk tend to be a cynical bunch and they’ve every right to be after 25 years of failure by governments to deliver reform of adult care and support. It should be no surprise that the response to the new white paper, People at the Heart of Care, has been less than effusive.

The sector’s verdict was put in a nutshell by Natasha Curry, deputy director of policy at the Nuffield Trust thinktank, when she told MPs this week (MON DEC 13): “Not enough people are able to access enough quality, affordable care at the moment and I have not seen a plan that addresses that adequately.”

But at least there is a white paper, which is more than some sceptics ever imagined, and there is a great deal to play for in the new year as it is fleshed out and built upon. So what should people of goodwill do to make sure the opportunity is not wasted and the 103-page blueprint does not join so many of its predecessors on a dusty shelf somewhere in the bowels of the Department of Health and Social Care?

Let’s consider the positives. Most observers are impressed by the objectives, principles and inclusive language of the white paper with its underpinning commitment to person-centred care. That alone ought to be enough to keep all stakeholders onside and actively engaged in further work to come, though it would be a stretch to say that the approach so far has amounted to real co-production.

The white paper recognises the essential and growing role that technology must play in care and support in future and it at last makes the critical link with housing, something blindingly obvious yet somehow missed in the past. Its assertion that “every decision about social care is a decision about housing” should be inscribed above the desks of care commissioners everywhere.

And because it was pre-announced, it would be easy to overlook the undoubted gain that is the commitment to a lifetime cap of £86,000 on liability for care costs. It may in practice help only a small minority, and its benefit for people with lower assets has been diluted by the Treasury’s insistence on counting only personal payments for care rather than any made by the state, but the measure will still provide a bulwark against catastrophic costs and may prompt insurers to come forward with products to mitigate individual exposure.

Finally, there is some funding for first steps along the road of reform. But it’s a measure of how slim the pickings are that the white paper boasts of £5m for a website to help people understand the changes, while “at least £300m to integrate housing into local health and strategies” is a vague pledge and certainly not a sum that will do anything to change the world over three years.

The lack of serious funding for the commendable aspirations of the white paper is its fundamental weakness. When Curry gave evidence to the Levelling Up, Housing and Communities Select Committee, she and representatives of the other two leading health and care thinktanks, the King’s Fund and the Health Foundation, agreed that about £7.6bn would be needed next year, over and above what is already committed, to meet people’s acknowledged needs with quality services, to make some inroads into unmet needs by growing by 10% the number of care packages and to enable care providers to improve the sector’s scandalously low pay rates.

It’s hard to see how the 10-year white paper vision can be realised in any significant way as long as the great majority of its 1.5 million paid workers earn wages at or just above the statutory minimum and have few prospects of building a career. This has to be a priority issue for 2022. But there must be help, too, for the most pressed unpaid carers who have performed heroics throughout the pandemic and whose reward in the white paper is a measly “up to £25m” to prompt a change in services that support them.

How, then, should the sector play its cards in the new year to sustain momentum on the reform agenda and disabuse politicians and the public of any assumption that the white paper is the last word on the matter?

Simon Bottery, senior fellow at the King’s Fund, has recently blogged thoughtfully for the Social Care Future pressure group on those tactics that have been heavily deployed, with mixed results, and others that might be tried. Arguments that could be characterised as moral/ethical, rights-based and “crisis!” have all failed to seal the deal, he argues, and there is little reason to believe that continued reliance on them will yield anything more than further drip-drip cash handouts.

More emphasis should be placed on playing to people’s self-interest, Bottery says, on social care spending as an investment in the population and the economy and on aligning the issue with broader policy goals. These could include wider workforce strategy, positive ageing and the levelling up agenda, for example, but there should be no policy to which the social care community should not consider hitching its wagon.

As Bottery concludes, tactics should be seen as complementary rather than mutually exclusive. And the sector must improve its evidence, its messaging and its discipline so that any selection of them needs not only to be crystal-clear on what tangible benefits would result from investment, but to leave our political leaders no wriggle-room to escape accountability for social care at national level.

One intriguing suggestion on accountability comes from the excellent Care 2030 report produced just ahead of the white paper by the Hallmark Foundation, mooting creation of an independent Office for Care and Ageing Well to monitor and report on unmet social care needs and changing demographics. That’s food for thought.

In the immediate term, though, there’s a clear imperative to inject some rigour into the white paper’s commendable but loose ambitions. Establishing a set of milestones would be an obvious way to focus minds and prevent drift. It’s going to be a long and tortuous journey of reform – and we’ll certainly need a good map.

David Brindle is a strategic adviser to Healthcomms Consulting and former public services editor of the Guardian

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