The NHS Constitution begins with the following statement:
“The NHS belongs to the people. It is there to improve our health and wellbeing, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well as we can to the end of our lives. It works at the limits of science – bringing the highest levels of human knowledge and skill to save lives and improve health. It touches our lives at times of basic human need, when care and compassion are what matter most.”
An admirable sentiment, but one which raises a question. Why do we not apply the same principles to social care, when they so obviously apply in moral terms?
Governments have betrayed us on social care, setting up commissions, proposing (and then retreating from) elaborate new policies, but taking remarkably little action. As a result, social care is in perpetual crisis – a crisis which will only be exacerbated by the march of demographic change.
The failure of our politicians to address the implications of an ageing population has created a slow-burning catastrophe. The Office for National Statistics projects that 26% of the UK population will be aged 65 or over by 2066, compared to 18% in 2016. The projected addition of 8.6 million residents represents a population roughly the same as that of London. Older people are more likely to have disabilities and long-term health conditions that require care services beyond those provided by the NHS. Barring extraordinary advances in medical science and technology, a larger and older population will need more of these services. If we don’t want millions of older people to live in misery, we need to find a way to provide for them.
The rising share of the population in old age is gradually dismantling the assumptions on which the welfare states of the twentieth century were built. According to the ONS, the average life expectancy in 2011 was 82.8 for women and 79 for men, compared to 55.4 and 51.5 respectively in 1911, shortly after the establishment of the first state pension. Even allowing for the fact that a proportion of this rise is due to improved medical treatment and reduced infant mortality, people are now much more likely to live for decades after retirement. Compared to the early 20th century, family and especially community ties are also generally weaker – at least in terms of the ability of older people to access unpaid care, which the National Audit Office values at £100bn a year. Although older people have previously benefited enormously from scientific and technological advances, there is no guarantee that such improvements will necessarily mean the future 65+ population is much healthier and more able to live independently than it is now. Meanwhile, the number of working-age adults needing social care services is also rising. The world where the state only had to support people for a few years after they stopped working, and where only a small minority needed long-term social care, is long gone – and it isn’t coming back.
The current English social care system (it should be noted that social care is a devolved matter in Scotland, Wales and Northern Ireland) is hopelessly unprepared to deal with the emerging reality. To begin with, regardless of what the House of Commons Research Library calls a “widespread consensus” on the need for a secure and sustainable funding settlement, even when it comes to day-to-day spending our social care services are desperately underfunded. Despite continuous rises in demand, the King’s Fund has concluded that adult social care spending is £700m lower in real terms than it was in 2010/11, with the cuts having fallen particularly hard on poorer areas. A joint report by the Health Foundation and the King’s Fund estimates that there will be a £6bn funding gap by 2030/31 without any change in provision levels or quality. The House of Lords Economic Affairs Committee estimates that an additional £8bn a year of funding is needed to restore pre-2010 levels of quality and access.
This ongoing financial disaster is complemented by a fragmented and confusing care system which, crucially, is not even free at the point of use. Recipients are means-tested to determine whether they are eligible for local authority support, with no limit on the amount they may end up paying. If someone in need of care has assets of more than £14,250 then they will have to pay something toward their social care, while if they have assets totalling more than £23,250, they will have to meet its entire cost. It is as if all citizens needed to be means-tested before they could use the NHS, and had to pay an unlimited amount out of pocket for medical expenses if they were ineligible for NHS support. But despite (or perhaps because of) the scale and political intractability of the issue, it is striking how poorly much of the public understand issues surrounding social care provision. Research by Deloitte reveals that just under half of people believe social care is free at the point of use, with over 60% believing that it is provided by the NHS.
The current system puts older people and their families into a horrible position. At a time when they or a loved one are experiencing worsening health and declining independence, they are often forced to navigate an unclear system and deal with significant financial pressure. The system as it stands is inequitable, and will only grow more so, given what we know about the socioeconomic distribution of the burden of disease, and the gendered distribution of care responsibilities. Put simply, doing nothing is unacceptable.
To overcome these problems and find a permanent, sustainable and humane way to support its ageing population, England needs to develop a new arm of the welfare state. A truly progressive social care system should be built around two main priorities: being free at the point of use, and providing high quality care.
The best way to do both is to establish a National Care Service as a single state provider of social care, free at the point of delivery and funded out of general taxation. (It is important to distinguish from the Labour policy of the same name. In its present state this is closer to a brand name for a series of good policies, rather than the recasting of the welfare state which is necessary to address one of the central problems of 21st century society)
A single organisation responsible for meeting all social care needs would be an enormous improvement on the current system, allowing the state to guarantee not only universal free provision, but also national quality control and a strong and unified workforce of social care professionals. It would ensure that users could benefit from economies of scale, allowing powerful new technologies to be deployed more easily, and – at least outside the private sector – it would virtually end the possible bankruptcy of smaller-scale providers which haunts the sector today. While it’s true that a universal free service would require public money to be spent on providing a significant benefit for middle-class people who currently fail the means test, this would be more than made up for by the advantages of a strong universal model, and the benefits for the worse off of a universal right to a minimum standard of free care. There would be countless details to work out – for instance, how far local authorities rather than Whitehall would actually provide the services – but these must be subordinate to the basic principle that a minimum quality of state-provided care should be available free to everyone in the ageing society.
Creating a free at the point of use system raises the obvious questions of cost and feasibility. But we only need to look to Scotland to see a comparable system in operation, where care at home is paid for by local authorities, in a policy introduced by the Labour/Lib Dem coalition in 2002 and subsequently maintained by the SNP. The Scottish system is less comprehensive for those requiring residential care: care costs are paid by the local authority, but the funding for accommodation costs is means-tested. However, as proof that a free at the point of use service is not out of the realms of possibility, Scotland is a good place to start.
There are potential alternatives to the blanket guarantee provided by a free state-provided service, but they would all be faced with significant problems. Private providers can play an important role in relieving pressure on the system, but they are an inefficient way of providing universal services, while the tireless work of specialist charities is never likely to reach a sufficient scale to ensure universal coverage. A private insurance-based system (which no other country uses) would be inherently demeaning to those who were unable to spend their lives working, lack the efficiency of a single provider, and in many cases be virtually unworkable due to potentially limitless costs.
The new National Care Service would face problems radically different to the institutions of the welfare state established in the 20th century. Most NHS services are provided in hospitals and clinics, where the sick congregate to be made well. By contrast, adult social care is overwhelmingly provided either in the home or in much smaller institutions than hospitals, to permanent residents whose care needs are likely to keep increasing instead of going away.
Adult social care also tries to solve a potentially bigger set of problems than conventional medical care. For example, besides mobility, washing, dressing, eating and continence, how far should the new universal service provide assistance with things like shopping, cleaning and laundry? The new service must be ambitious in recognising the need for a much broader level of state support than has previously been considered, but also wary of the need to minimise complete reliance and government intrusion into the most private parts of people’s lives. While playing an important part in reducing the need for unpaid care work – which falls disproportionately on women – it would also need to support and enhance existing family and community networks.
If the National Care Service is to provide sustainable high-quality care, then at the same time as setting up the new system we must change our attitudes to social care work. At present social care is considered a socially undesirable minimum wage industry – both the cause and consequence of having a workforce which is 82% female and disproportionately BME. As austerity has restricted local authority budgets, councils have in turn reduced or frozen the amount they pay to care providers, which, alongside the position of care workers in the labour market, means that wages in the sector are desperately low. In some places people would earn more working for a supermarket than for providing care to the sick and elderly. Given the level of skill and the physical and emotional exertion required in care work, it is no surprise that the care sector has a vacancy rate of around three times that of the economy as a whole. The United Kingdom Homecare Association estimates that just 14% of local authorities pay the minimum sustainable price for home care, meaning that in the current system, even small moves toward improving the position of those working in social care could threaten the feasibility of providers. A single state-run service, if properly funded, would be in a far better position to address low wages, and workers would also be able to benefit from more effective collective bargaining, reducing the likelihood of problems like those over sleep-in payments.
As well as providing better pay, the National Care Service would need to be supported with investment in improved conditions, education and professional development. The entire state workforce could operate under the Ethical Care Charter, to the benefit of both themselves and clients. A new generation of workers could be trained in specialist colleges established specifically for the purpose by the Service. The revamped workforce would be able to deal more effectively with a continuously growing army of increasingly socially isolated clients, and be more flexible in response to technological change.
This still leaves the problem of labour supply. Regardless of whether social care is reformed, to ensure it can actually hire the skilled workers it needs, the government needs to adopt a permanently more liberal immigration system. There is already a major shortage of skilled social care workers, in part because the highly restrictive immigration system makes it difficult to hire. Unless there is a major long-term rise in unemployment, this problem is almost guaranteed to get worse, as the proportion of the population needing social care increases while the working age proportion falls. A National Care Service could help solve this problem by operating its own visa scheme, separate to that of the Home Office (which should be abolished anyway), and having a recruitment arm actively seeking out workers across the world.
When it comes to the cost of a new care service, there are no good outcomes. Society is just going to have to accept higher taxes to provide decent services for an older population, with funding continuously increasing above inflation as the population gets older and its needs more complex. There have been some attempts at calculating what these new costs might look like. The King’s Fund and the Health Foundation recently estimated that introducing a basic service of free personal care for all eligible older people would cost £7bn a year in 2020/21. That would double in a decade to £14bn. (For comparison, the NHS England budget is about £115bn.) The researchers suggested that a 2p rise in the basic, higher and top rates of income tax would fund an elementary system of personal care across the country – though this option would do nothing to increase eligibility by need in social care. Creating a more universal system would require more significant funding. Domiciliary care would make these costs much higher, as would efforts to expand what is meant by free personal care. Indefinite tax rises are not pleasant but they are should not be cause for shying away, particularly when we consider the radical cuts that have been made to taxes such as corporation tax since 2010, where HMRC estimate that a 1 point cut costs the Treasury £3.1bn a year.
There is a genuine concern around intergenerational fairness here. Tax rises inevitably need to be levied on the current working population. Many of them have seen less favourable economic conditions in their lives than those who will initially be the main recipients of a reformed social care system. To this, there are two viable responses. Firstly, there should be a greater focus on raising tax revenue from wealth, which will mediate the intergenerational distribution effects. Secondly, politicians need some honesty and courage. Those of working age are going to pay one way or another, whether it’s through increased taxation, the burden of increased care responsibility when state provision falls short, or monetary payments to care providers. The money will have to come from somewhere, and the fairest way of getting it is through general taxation.
A National Care Service, providing universal free social care, would ensure that the services are provided in the most efficient way possible, while the ever-increasing cost is spread as fairly as possible throughout society. The scale of the challenge is immense. It is up to progressive politics to meet it, by building a new arm of the welfare state.