- David Oliver, consultant in geriatrics and acute general medicine
- davidoliver372{at}googlemail.com
Follow David on X/Twitter @mancunianmedic
In his recent report on the NHS, Ara Darzi said that adult social care was outside his formal remit except “to the extent that it impacts on the NHS,” adding that it was “impossible to understand what is happening in the NHS without understanding what is happening to social care.”12 But, given that he wasn’t discussing the issue, he managed to say plenty: for instance, that “the dire state of social care means 13% of NHS beds are occupied by people waiting for social care support or care in more appropriate settings”—with a knock-on effect on NHS activity and productivity. He discussed the need for a “shift of care” from hospital to the community, with “financial flows” to follow.
Adult social care doesn’t just support older and frailer people but also young and midlife adults with physical or learning disabilities or neurodiversity. Nor is it all about helping medically stable people to leave hospital or avoid admission but about enabling them to live life as independently and as well as possible. Unlike the NHS, it’s means based and hence heavily rationed on eligibility criteria (with a high threshold), not on need.3 Many people have unmet care needs, and this has worsened since 2010, as most care relies on unpaid carers—usually family members—who in turn often receive little support.45
For successive parliaments, long term solutions have been ducked and policy decisions have made a bad situation worse. The economic austerity policies of the 2010-15 coalition government led to deliberate cuts in national support grants to local authorities.6 Local government and hence social care funding haven’t recovered, and an ever higher percentage of local government spending goes on statutory adult and child social care services.7
The Institute for Fiscal Studies and the BBC have both reported that the most deprived local authorities were hit hardest despite higher levels of need.89 These local authorities have less ability to raise funding locally, given that council tax is based on property values and that other local government income comes from business rates. This is inherently regressive and entrenches inequalities in access to social care services.
Dropped commitments
Social care policy solutions have been relatively easy for successive governments to de-prioritise, delay, or ignore. While most people are familiar with using NHS services (which in turn are rarely out of the headlines), most people don’t use social care, so public understanding of its funding and provision is lacking, as is awareness of the boundaries between what counts as healthcare or social care.10 Social care consumes £28bn of government spending, as opposed to £181bn for the NHS.11 One might argue that this also makes social care cheaper to improve with a smaller cash uplift, but future population ageing means that costs will grow.
Since Labour was last in office the government’s focus on social care has largely been on funding—particularly on protecting individuals from catastrophically high costs. The Dilnot Commission in 2011 recommended a public-private partnership with a cap on individual care costs, a recommendation killed off by the 2015-19 Conservative government.12 After Boris Johnson’s 2019 election victory he promised a “lasting solution” to social care based on national insurance contributions for working age adults.13 In reality, the amounts of additional funding for social care would have fallen far short of the amounts that experts at the Health Foundation said would be required even to maintain current access, let alone expand it. Even those commitments were soon dropped.14
The Conservative government led by Rishi Sunak then promised to introduce a lifetime care cost cap of £86 000. But in July the new chancellor, Rachel Reeves, dropped even this modest commitment, which seems to have received far less attention than cuts to winter fuel allowances for pensioners.15
So, what are we left with? Well, Labour’s election manifesto promised a “fair pay deal” for social care workers, a commitment that remains free of detail.16 There have been vague hints from Wes Streeting, health and social care secretary, and from those briefing the media at cross party talks on the future of social care—but no firm commitment, with further plans still being worked on behind the scenes.17
Writing in the Times recently about this policy inertia around social care funding and provision, Paul Johnson, director of the Institute for Fiscal Studies, said, “If we, to our collective shame, are never going to find the political will to finance social care for some of our most vulnerable citizens, as it seems increasingly obvious that we are not, then it’s much less cruel simply to say so.”1819
Labour, as the party that created the welfare state,20 must do better. This is the kind of problem it should be in power to solve.
