The King’s Speech reveals a new government hitting the ground running – 40 new bills are being introduced within weeks of taking office, an achievement not to be underestimated. But not everything in desperate need of attention has made the cut. The most frequently reported omission is the two-child cap benefit cap, but equally pressing is the plight of adult social care.
The infamous Sue Gray ‘shit list’ (the high-risk register facing a Labour government) failed to even mention adult social care and now it is reported that the government is planning to set up a Royal Commission to find a cross-party consensus on the way ahead.
What are we to make of this? On the plus side it seems the Commission could be chaired by Dame Louise Casey, a renowned scrapper who would say what she sees. On the other hand, there is a powerful whiff of déjà vu, and the feeling that the ball is once again being kicked into the long grass.
Over the last 25 years, social care has been the subject of 12 government green papers and white papers, alongside five independent reviews and commissions, including a previous Royal Commission that sat between 1997 to 1999. The experience of that Royal Commission – on long-term care for older people – is instructive. It made four major recommendations relating to: free personal care, a cap on care costs for accommodation, the establishment of national care standards, and integration of services. We are still awaiting effective action on all of these.
It is doubtful if any other area of public policy has been subjected to so much kicking of the can down the road as adult social care. The bizarre point has been reached whereby legislation to fix the problems has been agreed and passed in parliament, only to be left in abeyance. The classic example is the cap on care costs for individuals and families, introduced in July 2015, programmed for implementation in 2016, postponed until 2020 and then further postponed until 2025.
In the meantime, people are still left facing life-changing costs to buy their own care. Funding reform was not included in Labour’s manifesto, though the new Health and Social Care Secretary, Wes Streeting, seems to be suggesting that the 2025 implementation will take place. Seasoned observers of the scene will be legitimately suspicious. Indeed, local councils are already telling the new government that they are insufficiently funded and equipped to put the cap into effect as scheduled.
Crisis in adult social care
Meanwhile the crisis in the sector is deep and worsening. The problems are well-established and have no further need of investigation by a Royal Commission: significant and long-standing underfunding of council budgets; severe problems of recruitment and retention in the care workforce; a failed market model, with providers struggling to survive; and steep rationing of access to support.
A further problem is the narrow understanding of social care that treats it simply as an adjunct of the NHS – a means of emptying hospital beds more quickly. The latest report from the Association of the Directors of Social Services lays out the impact on cash-strapped councils of having to meet the ever-growing complexity of cases. The pressure on the NHS to discharge patients more rapidly from hospital has left local councils having to provide ever more expensive support packages. In turn this has reduced the funding available for people needing early support at home, meaning their needs escalate more quickly and the strain on unpaid carers intensifies.
In the past, these complex packages of care would have been provided free of charge by the NHS, and now the task – but not the funding – is passed to local councils. As Lord Jeremy Beecham of Benwell was fond of saying, central government “passes the buck but not the bucks”.
What will Labour do?
Despite Keir Starmer’s best efforts to the contrary, hopes will inevitably be raised that a Labour government with a huge majority will ’do something’ about all of this. Sadly, the party manifesto was very guarded on the topic. There has been much talk of a creating a new model of a National Care Service to match that of the NHS, but there is no indication of what this would mean or how it would be funded. Certainly, it would be wildly optimistic to imagine an NHS-type model, free at the point of use and paid for out of general taxation.
More promisingly, the manifesto pledged to consult on a fair pay agreement in the sector, covering pay, conditions, and training standards, but again with no indication of when this might happen or how it will be funded. Simply passing the cost on to already struggling providers will only lead to more small businesses going under. This, alongside everything else, will presumably be left to the Royal Commission – a task of indeterminate length. Harold Wilson’s quip that royal commissions are a way of “taking minutes and wasting years” is evergreen.
Policy and legislation in adult social care
The idea of basing policy upon wide consultation, established evidence and a sectoral consensus cannot be faulted. The irony is that this is exactly what happened a decade ago, culminating in the Care Act 2014. This legislation – still on the statute books – established a widely admired set of principles and aims for the future direction of adult social care. It shifted the focus from ‘providing services’ to ‘meeting needs’ and required councils to do so while respecting individual preferences and identities.
This approach is vastly different to the traditional focus on the number of visits, and the focus on basic tasks of everyday living like washing, dressing, and feeding. The problem with the Act is (like the cap on care costs) that it was never properly funded to achieve its promise. Implementation coincided with the deepening of the Tory austerity years, but there will be questions as to why a Royal Commission is needed to reinvent the 2014 Act wheel.
As a recent report from the Local Government Association points out, successful implementation of the Act requires some well-established changes:
- An immediate injection of funding – meeting future demands and making some improvements to access to care that would cost £3 billion+ in the coming year.
- A comprehensive long-term plan for the workforce – Skills for Care has produced one very recently.
- A bold and ambitious approach to prevention.
- Authentic coproduction of support with people who draw upon it.
Long-term effects of marketisation
There is also a further problem with adult social care that all political parties choose to ignore – the long-term effects of marketisation. Forty years ago, local councils had a virtual monopoly of provision; today it has almost none. Rather the sector consists of a multiplicity of fragmented, competing providers – over 5000 care home providers and over 10,000 home care providers, with no connection between them. How can this be shaped into a coherent system that supports people to pursue the things that matter most to them?
All roads lead back to funding. The Institute for Fiscal Studies has referred to a ‘conspiracy of silence’ on the trade-off between public spending, taxation and borrowing. The first spending review conducted by the new Chancellor, Rachel Reeves, will tell us more on this point, but the suspicion will remain that setting up a Royal Commission on the future of adult social care is something that would appeal to Harold Wilson.
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