This article forms part of the LGA think piece series 'Towards a sustainable adult social care and support system'.
All too often, the funding of adult social care is seen as an economic and a technical issue: what’s the best mechanism for raising the funding we need? While this is important, the more fundamental questions are personal, political and philosophical: what kind of life do we want to have together as a society? How much do we value disabled and older people with care needs? What sort of support would we want available to any of us if we needed care? How much do we really value this and how much might we therefore be prepared to pay for whatever quality of life we decide we want?
With the NHS, the answer to many of these questions is usually very clear – none of us know when we may need to access health care, and we really value the fact that we have a health service based on clinical need rather than ability to pay, available to us all largely free at the point of delivery.
With adult social care, in contrast, we have a system that few people understand, that is heavily rationed and targeted on those with only the most severe needs and the lowest incomes, and that is means-tested and subject to very significant user charges.
Many people still assume that social care is funded in the same way as the NHS and will be available to them free of charge, and it often comes as a severe shock when people find out that this isn’t the case – usually when they are already in crisis and urgently need support.
Since the late 1990s, we’ve had major reviews and reforms of adult social care on at least 12 occasions, and we’ve tended to fail utterly to implement the key recommendations around funding. Typically, we end up concluding that all of the options seem too politically unpopular and we place social care in the ‘too difficult’ box, kicking the issue into the long grass for someone else to sort out in future.
While the Green Paper could be an opportunity to finally put this right, it could also be a question of history repeating itself. Whatever funding options we pick, there are a number of key issues and principles that we would do well to reflect upon:
- We need to ask why we fund social care differently to the NHS. For all the emphasis on integrated care, we have a system which assumes it’s possible (and maybe even meaningful) to distinguish between people who are ‘sick’ (who we see as having ‘health’ needs met free by the NHS) and people who are merely ‘frail’ or ‘disabled’ (who we see as having ‘social care’ needs which are met by local authorities and subject to means-testing). I don’t know if this distinction ever made sense, but it seems increasingly untenable given demographic changes and in an era of long-term conditions, when so many people have multiple needs which span traditional boundaries and defy easy categorisation.
- Rather than seeing adult social care as a basic safety net or a bare minimum, we could choose to see it as a form of social and economic investment that helps us all to live a good life and to contribute as active citizens. Indeed, when disabled people’s care needs are met and they are able to work, our social security spending should go down and our tax revenues go up – so spending on social care could be a good investment.
- We need to explore how much funding services need to deliver the quality of care and coverage that we say we want. Just changing who pays doesn’t change the overall amount of funding available. Indeed, some potential mechanisms could place even more pressure on local authority budgets without actually increasing the money available – surely a worst case scenario.
- We need to strike a better balance between the national and the local. At present, the costs of publicly funded adult social care fall on cash-strapped local authorities, who are struggling to meet their responsibilities in the face of widespread cuts, and who are having to make even more draconian reductions in other services in order to protect spending on children’s services and adult social care as best they can. Recent injections of cash have also fallen on the council tax, which is highly regressive and can only ever be a sticking-plaster solution.
Above all, whatever options we pick, we have to seek cross-party consensus and we have to commit to implementing our decision.
This is partly about the vision and courage of political leaders, but it also applies to all us. If we demand a solution to the funding of adult social care, then resent the person or party who delivers what we asked for, we’re just as guilty as policy makers for failing to resolve these issues. Perhaps we get the quality of adult social care we deserve as a society, and the Green Paper is an opportunity for all of us to commit to something better and more comprehensive than our current uneasy compromises - the trick is that we have to really mean it when we say it.
Professor of Health and Social Care and Head of School of Social Policy, University of Birmingham