Social care reform – comprehensive is good, but comprehensible vital

Chris Game

Cllr Ketan Sheth’s recent blog on ‘Local Government and the NHS Integrated Care System’ was, as he explained, timely for him personally – as an elected London borough councillor about to take on a novel scrutiny role in a new ICS.

For us Midlands readers it was timely too, for reasons most easily conveyed by the King’s Fund’s recent highly colourful Map 1 of ICSs so far established – highly colourful, that is, for some parts of England, including Cllr Sheth’s London, but bleak grey for others, like the whole of the Midlands, with merely our at least slightly more localised Sustainability and Transformation Partnerships (STPs).

This blog is not directly about either STPs or ICSs, which have only a late walk-on role. It is, though, about the future of social care and local government’s involvement in, or marginalisation from, that future, and it opens with one of Boris Johnson’s first Prime Ministerial broken pledges, in his very first speech as PM, to “fix the crisis in social care once and for all with a clear plan we have prepared”.

The ‘clear prepared plan’ bit was obvious fiction, and confirmed as such in the Conservatives’ December election manifesto.  60 pages, nearly 1,000 days working on a promised but still undelivered Green Paper, and no sniff of a plan.  One un-costed pre-condition (p.23) – that nobody should have to sell their home to pay for care – and a slightly desperate hope to build cross-party consensus on reform.

But last week, just eight months on, jostling with daily lockdown bulletins and courtesy mainly of The Guardian newspaper, saw a sudden small flurry of tantalising leaks. First came Ministers’ “radical plans for everyone over 40 to contribute towards the cost of social care in later life” – paying more in tax or national insurance, or insuring themselves against “hefty care bills when they are older”.

Broadly resembling the German and Japanese funding systems, it is variously labelled a ‘comprehensive’ and ‘compulsory’ insurance model, both of which, to be effective, it surely has to be.

But an even bigger question, I suggest in the blog’s title, is surely whether it can become a comprehensible and comprehended model, and pretty quickly – because the evidence is that our collective understanding of even the existing system is worryingly low.

With coincidental but near-perfect timing, the New Statesman magazine recently commissioned a poll by Redfield & Wilton Strategies asking a sample of 2,000 GB adults about their awareness of how social care is currently funded and organised. Its findings, for a topic dominating news headlines for several months now, were concerning.

Fewer than one in eight felt they were “significantly aware”, under half even “moderately aware”, and nearly a quarter “not aware at all”. They were then asked which of (1) the NHS, (2) private operators, and (3) my local council, they thought were currently providing community care in their locality.  Being a GB-wide sample, there are no precisely right or wrong answers, and ‘providing’ makes it almost a trick question – which personally I’d have opposed phrasing in this way. Still, there are better and worse guesses.

“My local council”, chosen by 55%, is a decent pick – if, by providing, you mean paying for.  But not, for decades now, if you mean actual care home beds.  As Covid has tragically demonstrated, funding is nowadays effectively separated from extremely fragmented provision, with only some 3% of beds directly provided by councils and at least 80% in over 11,000 homes by for-profit private companies, local organisations and charities.

As for payment – roughly £600 per week here in the West Midlands – just over one-third of residents have their fees met by their local authority; one in eight pay top-up fees, but the biggest fraction must find the full fees themselves.  Which, given our apparently limited understanding of the present-day system, must frequently come as a serious shock.

Exactly half the poll respondents ticked the “private operators” option. However, virtually as many (48%) nominated the NHS, which, note the authors, is nowadays “a very small player” indeed in providing social care.  It’s not totally wrong, but close – and that, in the proverbial nutshell, is Ministers’ social care problem.

The public generally have low understanding of how even the present care home system works, of how literally dis-integrated it has become, with home care provision twice as fragmented and considerably more expensive. But they love, clap for, and think they know ‘their’ NHS.

It was even more starkly highlighted in the crunch question: “Which of three options for the future of social care comes closest to your own view?”  Exactly half the respondents selected the ‘NHS model’ that many had just demonstrated they seriously misperceived: “Social care should be free at the point of use, regardless of whether individuals contributed taxation into the system during their working lives”.

Just over one-third preferred the ‘pension’ or ‘compulsory insurance’ model referenced in the Guardian story – or, rather, first story.  For, the following day, it reported Government plans to in effect merge health and social care services, taking the latter away from local councils altogether and handing them and their £22.5 billion annual funding over to the NHS.

The Department of Health and Social Care issued a routine denial, but the PM’s long awaited ‘plan’ appears, currently, to be that care services would be commissioned by, and funded through, the new NHS regional Integrated Care Systems (ICSs) gradually unrolling across England – although not, as yet, the Midlands, where we’re still in the Sustainability and Transformation Partnership phase.

I conclude with what seems a bit of a personal dilemma. Having worked for over half my life for an ‘Institute of Local Government Studies’, I instinctively deprecate both the fact and implications of elected and accountable local authorities losing a major function for so long integral to their existence.

On the other hand, if that’s what most people reckon they want, and the Government fundamentally misunderstands, distrusts, and already wants to diminish and/or abolish local councils ….   The question is: would the public be prepared to pay the cost of NHS-style “social care, free at the point of use”, largely unaddressed in the New Statesman questionnaire?  But that’s for another blog.

 

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Chris Game is an INLOGOV Associate, and Visiting Professor at Kwansei Gakuin University, Osaka, Japan.  He is joint-author (with Professor David Wilson) of the successive editions of Local Government in the United Kingdom, and a regular columnist for The Birmingham Post.

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