Principles, politics and money

By Richard Humphries, The Kings Fund



This week Secretary of State for Health and Social Care Jeremy Hunt used the occasion of World Social Work Day to set out seven principles around which the much anticipated, if delayed, green paper for adult social care would be framed. We shouldn’t get over-excited about one speech. The Secretary of State himself acknowledged the numerous white papers, green papers and funding reviews over the last twenty years and confessed to ‘’feeling the weight of stalled reform programmes” on his shoulders.

Principles are of course important. Who could disagree with a vision for social care that includes:

  • Person-centred serviced that support independence rather than dependency and give people more choice and control
  • Partnership working across all sectors to offer integrated services that make the best of use resources and harnesses the capacity of the whole community
  • High quality services delivered by a well-trained workforce and better supported unpaid carers
  • Making better use of technology and a wide range of supported housing options
  • A greater focus on prevention and the promotion of wellbeing

Except the above words are not from Jeremy Hunt’s speech but from the 2005 Green Paper Independence, Wellbeing and Choice. This invites the conclusion that governments of totally different political complexions can actually agree what a better social care system should look like. It is the means to achieve it where the consensus begins to dissolve. There will be little point in producing yet another green paper without learning the lessons of why previous efforts have failed and drawing on the experience of other countries that have managed to implement introduce and sustain major reforms.

#Socialcarefuture is important because it addresses directly the question of what needs to be different this time and offers opportunities to engage a wider range of voices way beyond the ‘usual suspects’ of formal consultations. As Rich Watts argued, we desperately need new thinking about the ‘how’ of reform as well as the ‘what’ and ‘why’. Neil Crowther makes an eloquent plea to replace the language of crisis, burden and demographic timebombs to a more positive narrative based on the good that social care does. Other blogs in this series have highlighted examples of what better social care can look like. But inadvertently they also illustrate some of the really tough dilemmas that have assailed past efforts at achieving lasting change. As befits a sector that professes to care for people, our collective desire to be nice to each other might cause us to shy away from surfacing disagreement and difference about some of the solutions.

For example much of the debate ends up with the articulation of binary positions -investment in innovation versus traditional services; the financial position of commissioners as opposed to providers; the virtue and vices of publicly owned services compared to private and voluntary providers; the needs of working age people as against those of older people; protecting people from catastrophic care costs whilst ensuring adequate funding for people without wealth. The result can be a diaspora of disparate, and sometimes discordant, voices pitching their own particular idea, solution or set of interests. These are often legitimate and well evidenced but lack an overall appreciation that we are likely to need a range of different solutions for different needs and circumstances in different places. The principles outlined by Jeremy Hunt are helpful in representing a rounded view, relieving fears that the green paper would focus only on older people and money at the expense of key issues such as workforce and innovation.

There is also a fundamental question, originally raised by the late Derek Wanless, of what is the purpose of social care, what is trying to achieve, what is it for. These questions were never resolved in the 1948 settlement. The intention of the Care Act was to shift the focus from dependency to wellbeing. Vidhya Alakeson in her post rightly emphasised the importance of communities and the social infrastructure in creating a sustainable future for social care. And who could disagree with Alicia Wood’s aspiration for “…a care and support system that enables the people that use it to experience love, friendships and relationships, have meaning in their lives and be valued and contributing members of their communities.” Jenny Morris reminded us that for disabled people, independent living is not just about social care but the ability to go about daily life with access to  equal access to housing, transport and mobility, health, employment and education and training opportunities. Human rights, citizenship, wellbeing are all totally admirable aspirations. But how realistic is it for a predominantly state funded and local authority managed system to be freighted with such enormous expectations that extend way beyond its ambit? Even with far more generous funding, there is a danger that we expect more from the social care system than we do of God. It seems improbable that municipal officialdom could have much of an impact, for example, on the modern epidemic of loneliness and isolation, and nor should it be expected to. A strong universal social and economic infrastructure is prerequisite of an effective social care system and underlines the criticality of social care reform being rooted in wider social and economic policy objectives, as Japan and Germany have shown. The social care system on its own cannot solve all social ills.

That in turn raises the controversial question, that for some dare not speak its name, about the role of local government in the future of social care. The high priests of localism will be outraged by the faintest suggestion that councils might be part of the problem and not part of the solution. Evidence mounts that traditional commissioning and contracting is neither effective nor sustainable in meeting individual needs. There is too much variation between councils that can’t be explained by different local needs or resources (noting that this also can be said for the nationally-run NHS). A shift towards some kind of social insurance system would almost certainly lead to the wings of councils being clipped as entitlement to help is determined nationally and not subject to local discretion. There is a strong argument that councils could play a more effective – and bigger – role in shaping community capacity and promoting wellbeing at a population level than administering highly means-tested and rationed care services or policing the fraught boundary with the NHS.

These are some of the wicked issues that explain why successive governments have struggled to sort out social care and in recent times have led me to conclude that if there a single ‘big idea’ in social care it is that there is no big idea, instead a multitude of small ideas that can work well if they are well implemented, rooted in local circumstances and developed from the bottom up. But this doesn’t sit well with popular demands for national consistency and access, as witnessed by calls by disabled people during the passing of the Care Act for complete portability of assessments and care packages. And if all solutions are local, so too are many of the problems, as we have seen, hence the inference by Jeremy Hunt of a more muscular approach to overseeing local commissioning. How to balance the competing tensions of local innovation and control with national accountabilities, entitlements and oversight have been an enduring thread in the history of social policy as successive social care ministers have discovered. I am impressed by the efforts of places like Greater Manchester, Northumberland, Nottinghamshire and Dudley to achieve wholesale system change across health and social care, designing their own solutions and work-arounds to some of the national barriers. As Chris Ham observes, they are writing their own manual for integration, not implementing someone else’s template.

Finally, to borrow a Springsteen lyric, there is the matter of ‘good cold cash’. The oft-quoted mantra that ‘it’s not just about the money’ doesn’t mean that it is not at all about the money. Alex Fox has set out a compelling and persuasive argument for a more human approach to long-term care that would avoid much of the waste and unnecessary costs of the current system. But he makes a crucial point that ‘no new health and care system can cost less than the current one’. To take one example, the cost of a better trained and properly paid workforce, with better career pathways, will be huge. A perverse outcome of austerity is that an even bigger proportion of what money there is gets spent on the most expensive services that often deliver the poorest outcomes, whilst spending on prevention has collapsed. A dilemma for the government is how to break out of that cycle without jeopardising provider stability and continuity of care for existing recipients of care and support.

Social care will never work properly without adequate and rising investment. It is now competing for extra resources with a wide range of other priorities that include the NHS, housing, prisons and public sector pay. How it fares will depend as much on raw politics as much as any intellectually elegant and evidence-based case for change.















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