It’s social care funding reform season! Every few years, a brave Prime Minister confronts the beast of adult social care funding reform, only to be beaten back by a partisan and opportunist opposition labelling their proposals a ‘death tax’, a ‘dementia tax’ or something equally diabolical, and the dark forces of the Treasury undermining the reforms from within.
Is this time different? Yes and no.
For two decades, we have declared there is a crisis in adult social care. The system has been on ‘the brink of collapse’ and about to step over the ‘cliff-edge’, for as long as we have worked in and researched the sector. There have been commissions, white papers, and reforms of the care system, yet the funding of an expanded public system still evades the UK (despite the variations in the devolved administrations). Boris Johnson, as he took office as Prime Minister in 2019 said, ‘we will fix the crisis in social care once and for all’. Leaving aside the problem that adult social care is not a ‘problem’ to be ‘fixed’ (no one would describe the NHS as a problem, or a finished project), this was a statement of huge ambition, given the failure of Tony Blair, Gordon Brown, David Cameron and Theresa May to significantly change the system of funding for public adult social care.
The absence of legislative change on funding care in England means that social care has drifted into crisis. We still means-test on the basis of 2010–11 figures, excluding more and more people from eligibility for support, increasing the ‘self-funding’ market in England particularly. The lack of new public investment has also meant an increase in cross-subsidisation by these self-funders, as they effectively top up the low fees that local government pays for people it supports. Almost half of English people who use social care pay for themselves.
Policy scholars have used the concept of policy drift to explain why important questions like social care funding fail to be addressed. As Hacker puts it, ‘[drift is] a result not of failures of foresight or perception, but of deliberate efforts by political actors to prevent the recalibration of social programs’.
But who would do such a thing?
In the early 2000s, a minority report, influenced by Tony Blair’s Policy Unit, undermined the Sutherland Commission’s recommendation that Personal Care be provided free and funded through general taxation. Then the Conservatives’ ‘Death Tax’ campaign stymied Andy Burnham and Gordon Brown’s plans for a ‘National Care Service’ in 2010.
In 2014, the Treasury (as well as an overwhelmed and poorly funded sector itself represented by ADASS and the LGA) helped kick the Coalition’s planned funding cap into the long-grass. In 2017, Theresa May’s manifesto plans were derailed by the campaign against the ‘Dementia Tax’ led by the Labour Party. A combination of internal veto players and political polarisation have led to a state of seemingly permanent drift. Social Care seemed to be the toxic political issue that no one wanted to pick up.
And yet this week, MPs voted to support a £12 billion a year tax rise for health and social care, and the government issued proposals to revive the cap on care spending, and reform the means test so that anyone with assets below £100,000 will get some state help.
So what is different this time around? Well, first we are relatively early in the political cycle. The last election was in 2019. With a fair wind the Conservatives may have three more years before they take their tax rises (and broken manifesto promise) to the voters. The Conservative majority is large and Boris Johnson’s Teflon style of leadership seems to allow him to get away with things that his party would otherwise block.
Internal relationships at the top are also important. The Health and Social Care Secretary Sajid Javid was previously the Chancellor so may have been able to make the case in a convincing way overcoming the Treasury veto. Rishi Sunak, the Chancellor, has spent a lot of money on the Covid response which may have given him a taste for spending his way out of a crisis. The framing is important too – this is a ‘health and social care levy’ – and most of the money will go to health. Politicians and the public seem much more willing to spend money when there is a ‘saving the NHS’ spin on it.
The social care reforms amount to some money (£5.4billion over three years) and a revival of the cap that is already in law under the Care Act 2014. Lots of people in the care sector have rightly been critical of the lack of vision and ambition in the reforms. But it is clear that something has been done after years of delay. Whether this is the end of drift, and a step towards a fair and high quality care system in which people can flourish, remains unclear.
Patrick Hall is a social care policy researcher with over a decade of experience in the sector with a background in local government. He works on the Sustainable Care programme as part of the research team Comparing UK Care Systems: prospects, developments and differentiation in the 4 UK nations.
Professor Catherine Needham is Professor of Public Policy and Public Management in the Health Services Management Centre, University of Birmingham.
Catherine is the lead for Comparing UK Care Systems: prospects, developments and differentiation in the 4 UK nations. To better understand the factors which support sustainable care, this work package compares care systems in the UK’s 4 nations.