It’s All About The Politics

By Alan Rosenbach

Social Care has always been and always will be political and so about money and power. To see how we might shape the future for social care we best understand the recent past. “The rise of the welfare state in the late 19thCentury was in response to the growing popularity of left-wing politics, especially among the working class. Conservatives and Liberals in the late 19th early 20thcenturies could see no greater threat to their political position than that posed by socialism[1]“. The socialist aims were for a much greater role by the state in tackling poverty, poor health and inequality between rich and poor. The response by the ruling elites was to cede ground on meeting health needs in the early 20th century through voluntary hospitals meeting acute care needs and a means tested pension for older people by 1908.

Then, as now, the majority of carers were family members looking after their older or disabled relatives. We should not romanticise this idea. High rates of death in children, families moving away, immigration and war meant many disabled and elderly people had no support.

Left-wing politics in the middle of the 20th Century shifted the debate from the deserving and undeserving poor to the setting up of the National Health Service, free at the point of use, and the National Assistance Act at the same time in 1948, which means tested social care. The concept of the state supporting you from cradle to grave was established. So successful has this system become that we are all living longer, which may or may not be a good outcome.

We have learnt along the way that support in or closer to people’s homes and in communities rather than in institutions leads to improved health and well-being. We have shifted from local government running services to the development of less than perfect public service markets for care and support. We shifted from:

  • Professionals deciding what is best to
  • Central government targets to
  • Voice of the consumer to
  • Choice of the person using service

being the driving factor in market design. Voice and choice are still somewhat limited and there is a gap between rhetoric and reality. We have the not-for-profit sector, the public sector, voluntary and private sector all contributing to care and support. There are debates about small being beautiful, particularly if it is not-for-profit, versus large being less than satisfactory, particularly where the for profit sector is the provider. These are features of imperfect public service markets.

So, what of the future for social care? It looks bleak not least because we would need to double run the funding of care and support from the ‘as is now’ to where ‘we want to be’. Unfortunately, ‘we’ don’t have a consensus about where we want to be and how we might get there. I have great faith in experts, but we don’t have a determined evidence base about what works best for older people’s support or for working age adults in terms of service configuration and interventions, or a requirement where we do have the evidence that these must be implemented. We also have a significant problem with workforce shortages.

Let’s scenario plan here in summing up. We are designing a sustainable system for care and support that would help us to shift from our current broken system to one that works for individuals and families. What do we need?

Funding a care and support system that is:

  • Funded by general taxation for working age adults;
  • Funds through general taxation dementia care;
  • Funds through general taxation end of life care;
  • Abolishes the role of local government as a conduit for funding;
  • Makes financial resources directly available to citizens through the benefits system;
  • Extended investment relief for companies developing new technologies including artificial intelligence capability to improve care and support;
  • Enhancing tax and housing benefits specifically for those choosing a career in care and support;
  • Defining and implementing integration between health and care where the evidence supports an initiative of this type.

We have regressed back to the idea of the deserving and undeserving poor and we have come to see the welfare state as a burden. We have allowed the poor to carry the burden of economic failure, privatised the profits and nationalised the failures in economic policy. The most recent analysis of satisfaction with social services makes for grim reading. Satisfaction was 23% in 2017. The change from the previous year was not statistically significant. At the same time, dissatisfaction with social care services increased by 6 percentage points in 2017 to 41%[2].

What might services look like that meet need?

There are today aspects of care and support that meet the needs of individuals, families and parts of communities. These are all predicated on managing the asymmetry of power. In these circumstances, the state and its institutions are prepared to cede power determinedly and purposefully back to the individual, the family and communities. Importantly they come in all shapes and sizes. This series of blogs have highlighted the work of Community Catalysts, Shared Lives Plus, Local Area Co-ordination and community well-being teams. I know from my experience of working with the voluntary and for-profit sector that these services too cede power away from the staff to individuals.

Social care must find a coherent and articulate political voice that spells out the inequities of the asymmetry of power between state its institutions and citizens; highlight the positive approaches of services ceding power back to communities. It must do so in such a way that it threatens the status quo and so drives the positive change.


[1] Richard J Evans, The pursuit of power; Europe 1815 -1914.

[2] Kings Fund: Public satisfaction with the NHS and social care in 2017 Results and trends from the British Social Attitudes survey.

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