Unhelpful framing of what social care is in public debate has compounded financial pressures and hampered reform. Debate has too often reduced social care to a narrow caricature of residential homes for older people concerned about selling their property to pay for care.
As the Care Act was placed on the statute books in 2014, the mood in social care was optimistic. Reform had been a long time coming, with hopes for improvement repeatedly raised and dashed over the preceding 15 years as commissions, reviews, green and white papers were launched and then abandoned. The Act marked a significant milestone, consolidating an array of complex laws, establishing new rights for people who draw on support and their carers, limiting individual care costs, and placing new duties on councils to shape markets and promote wellbeing. A collaborative process of development resulted in high levels of support among stakeholders and across the political divide for the principles enshrined within it.
Fast forward ten years and it is difficult to find the same levels of optimism. Social care is in a perilous state with long waits for care; high numbers of people struggling to get the care they need; carers doing more hours with less support; and providers struggling to fill vacancies and make financial ends meet. Furthermore, the long-promised dream of seamless integrated health and social care remains just that and the promise to cap costs remains elusive. So, why has the promise of the Care Act not come to pass and how could things look different by 2034?
Legislation is the easy bit
The Care Act remains a powerful piece of legislation that continues to shape law, policy and practice. The underlying principles laid out in the Act remain just as relevant today as they were in 2014 and were evident in the 2021 White Paper’s ten year vision. But further tangible reform has stalled.
Although shepherding such a complex piece of legislation through Parliament was no mean feat, the real hard work came at implementation stage and the Act faced considerable challenges.
Passed at the height of austerity, the financial backdrop cast a long shadow and increasingly dominated implementation discussions at a local level. The most visible casualty was the cap on costs – at first delayed and then abandoned, reinstated and then again delayed in response to councils’ financial concerns. Less visible has been the chipping away at other elements in the Act.
Sporadic injections of funding have created a culture of uncertainty, which has limited the ability of councils and providers to innovate, invest, and shape markets.
Prevention – the very nature of which requires upfront investment for long-term and often difficult to measure gain – became an easy target for councils which are bound by strict annual budget cycles and spending duties.
This environment has driven behaviours and practices that run counter to the Care Act, with care too often reduced to packages, hours and minutes, divorced from considerations of wider wellbeing, prevention and choice. Furthermore, powers bestowed on the CQC in the Care Act have proved to be too reactive, providing few levers for proactively driving improvement. Variation in provision has been exacerbated by increasing reliance on local revenue raising.
Unhelpful framing of what social care is in public debate has compounded financial pressures and hampered reform. Debate has too often reduced social care to a narrow caricature of residential homes for older people concerned about selling their property to pay for care. As a starting point for debate, this holds little relevance for a large proportion of the population and fails to create a collective narrative. With low public awareness of social care, proposals for raising new revenue for reform have failed to build a case to the general population, quickly becoming politically toxic as a result.
All is not lost: learning from elsewhere
This all makes for bleak reading but all is not lost. Beyond the headlines, social care remains a vibrant and inventive sector with many examples of excellent and innovative practice.
But these positive instances are not widespread and survive in pockets in spite of, not enabled by, the context in which they exist. Comprehensive reform is needed if the full spirit of the Care Act is to be realised, but is it impossible?
We are not alone in the challenges we face and there are examples of other countries successfully reforming their care systems from a similar starting point. Japan and Germany are two that have responded to growing need and, while their systems are not perfect, they have successfully implemented sustainable funding, consistent eligibility and stable provision. The approach they took to building support for reform holds many lessons for England.
Both countries were successful in building public support for change by creating a positive story, framing social care as an essential part of national infrastructure. Japan, in particular, shifted debate from a negative framing of costs and burdens to a positive place where the system would not only provide high-quality support to individuals but also to wider society and the economy by freeing up unpaid carers and generating economic growth through a thriving provider sector. Germany, too, created a narrative centred on solidarity and mutual support. France is embarking on this journey and has recently established social care as the fifth pillar of the welfare state, bestowing on it a status and value equivalent to health and pensions.
In our society, we accept that healthcare and education are public goods – we all pay in and all benefit. Childcare, which has many parallels with social care, has experienced a shift in recent years where pledges by politicians to invest and expand the public offer have largely become vote winners.
The social care narrative needs to make a similar shift if we are to escape the spiral of failed reform.
The Care Act provides the foundational principles that should continue to guide change. But legislation can only take us so far. Consistent and determined political leadership is needed to drive through a comprehensive reform of social care, addressing not just funding but all issues that face the sector. For if we simply tinker at the edges, we risk arriving in 2034 with another wasted decade behind us.
