Social care reform: ambition vs reality

Last month, the National Audit Office (NAO) released a damning assessment of the social care system in England and the government’s record on the issue. Covid-19 has drawn attention to social care ​‘as never before’, argues the NAO, and ​‘the lack of a long-term vision for adult social care coupled with ineffective oversight of the system means people may not get the care that best supports them’.

The NAO are right to point to a need for a long-term vision for adult social care. It’s been four years now since the government promised a green paper on social care. And it’s been almost two years since they promised to ​‘fix the crisis in social care once and for all’. Yet nothing has been done.

Very little is even known about what the government’s priorities for reform are. When they have been pushed on the issue, Boris Johnson and other government ministers have repeatedly used the refrain that ​‘people shouldn’t have to be forced to sell their homes to pay for their care’. True, but this is a low bar for reform. Especially when compared to previous ambitions for the care system.

The Care Act, passed in 2014, set aspirations for the social care system in England. According to the Act, the goal of social care is to promote wellbeing, or to ​“help people to achieve the outcomes that matter to them in their life”. What this could mean in practice is captured very nicely by a quote from Social Care Futures: ​“We all want to live in the place we call home with the people and things that we love, in communities where we look out for one another, doing things that matter to us”. The job of the social care system is to support people to achieve these things. It is a vehicle to enable people to do what they have reason to value, rather than merely a destination, like a care home, which is the way that many of us have come to think of it.

The wellbeing principle sets out an admirable ambition for care, with similarities to calls for independent living — for years advocated by the disability rights movement — whereby ​‘all disabled people have equal rights to live in the community, with choices equal to others, and be fully included and able to participate in the community’. The act signified a promising change in approach away from the life and limb care that has dominated since the establishment of the welfare state, where the care system was tasked with ensuring people were fed, washed, and dressed: the minimum of survival and little more.

A good ambition for social care reform would draw from the wellbeing principle of the Care Act and the calls for independent living. Reform would aim to create a rights-based system that enables people to be and do what they have reason to value, on the same terms as everyone else. Rather than just the delivery of basic tasks to people, the care system would work with people to define what they want to achieve and work collaboratively with them to achieve it.

The problem with the Care Act, however, was that the reality came nowhere near the aspiration. The wellbeing principle lacked teeth, was passed into law while councils were being cut to the bone and the social care system was simply not set up to deliver on these principles. During the early stages of the pandemic, the government even suspended key Care Act duties, with councils only having to meet needs if required to avoid human rights breaches. A very low bar indeed.

As we move from our emergency response to recovery from Covid-19, the government will be under increasing pressure to set out its stall on social care and finally take some action. There is evidence that public appetite for social care reform is high.

Whatever the government comes out with needs to match the high aspirations previously set for social care in the Care Act, with a vision for care based on wellbeing, rights, and capabilities at the centre. Crucially, it also needs to learn from previous mistakes and propose changes to close the gap between aspirations for social care and the reality in practice by aligning the way that social care is provided with the vision, ensuring support is available to all based on need rather than ability to pay, and developing a funding settlement that is sustainable and spreads costs equitably across society.

Without doing so, we will continue to find ourselves in a situation where, in the NAO’s words, ​‘levels of unpaid care remain high, too many adults have unmet needs and forecasts predict growing demand for care’.

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