On 5 July, 70 years of the NHS was celebrated across the country with tea parties, live music, exhibitions and a host of other events. But on that day, what was the million-plus social care workforce doing?
This year is also the 70th anniversary of the social care system – but there will be no TV documentaries, prime ministerial funding announcement or national tea party.
The lack of focus on social care was perhaps understandable in 1948 when life expectancy for men was just 66. Seventy years on and so much has changed for the better – but social care’s position as the ultimate Cinderella public service hasn’t, despite almost one in four older people needing help with daily living.
NHS funding has increased during the austerity era, but social care spending was cut by nearly 10% in real terms between 2009/10 and 2016/17. Over that period, the number of over 65s increased by more than a million. At least 400,000 fewer people were able to access care by 2013-14 – and more than a quarter of social care staff leave every year.
Given the funding and staffing backdrop, it’s not surprising that the Care Quality Commission reports that one in five care home providers require improvement. And the problem is not going away. Academics at the London School of Economics project that, between 2015 and 2040, the number of disabled older people will rise by 67%. Social care budgets are now rising, but not by enough. In England, we face a large and growing funding gap – of around of £6bn by 2030.
Since Sir Stewart Sutherland chaired the royal commission on social care in 1999, we have been trying and failing to reform the system. The health and social care committee has just published a report with many echoes of Sutherland’s.
There is a risk that the government is going to duck the issue and social care reform will be kicked down the road yet again. The prime minister has committed £20bn to frontline NHS services – but has said almost nothing about social care. Meanwhile, the promised social care green paper has been delayed again.
What is it about social care that makes it so difficult to reform? A recent study by the Health Foundation and the King’s Fund – much quoted in the select committee report – offers some clues. Unlike the NHS, social care has relatively little public salience. Despite being around for 70 years, people’s awareness of how it works is incredibly low, with many believing it to be free at the point of use like the NHS. Very few understand that it’s means-tested, with only those with assets under £23,250 getting any publicly funded help.
When the means test is explained, almost everyone agrees that the current system is unfair. But what counts as fair is complicated. The health and social care committee has raised the prospect of a charge on inheritance tax to contribute to social care. This has been discussed before. In 2010, Andy Burnham proposed a £20,000 compulsory levy on people’s estates. Conservatives dubbed it the 'death tax' and the proposal sunk under the weight of electioneering.
Tax experts think the UK doesn’t have the optimal balance between taxing wealth and taxing earnings. We are also increasingly worried about intergenerational fairness but the English are really attached to home ownership and passing on their home to their children. Research shows that there is a keen sense of unfairness around any system that asks people to contribute housing wealth to fund social care, as happens now.
This takes us back to the awkward problem of money and priorities. Fixing social care is going to cost money – more than any government could afford after eight years of austerity and sluggish economic growth.
Twenty years ago, the Sutherland commission couldn’t reach a consensus on social care funding; the majority backed the idea of free personal care. The attractions are obvious, but it’s expensive – an extra £14bn by 2030. The problem is, none of that £14bn would go towards helping people with limited income and assets who have pressing needs but are caught below the threshold, which has tightened as austerity has bitten.
Improving quality and access for the most vulnerable would clearly be desirable and fairer, but it also has a price tag. If you can’t do everything, which unfairness takes precedence? There are no easy answers. But to duck the questions now would be a failure of our political system. Social care may not be the most visible public service but that doesn’t make it any less vital.
Anita Charlesworth (@AnitaCTHF) is Director of Research and Economics at the Health Foundation
This article was originally published on The Guardian