Social care: Making a more convincing argument for reform

Simon Bottery – The Kings Fund

 

The stark reality of adult social care policy is that no government has been willing to invest the political capital required to make reform happen. The current government is as close as any but its reforms are now faltering.
 
To what extent must the social care sector itself bear some responsibility for this situation and what might be done about it? In this blog I explore one aspect of this – the main arguments used in favour of reform, their strengths and weaknesses – and suggest how they might best be developed.
 
I see three main arguments which have been used to date – and three more that have had little or no usage but which could prove valuable.

 

First the ones that have been used extensively.
  1. Moral/ethical: ‘Society should do more for older/disabled people’. This is often the mainstay of the sector’s arguments and it can be powerful. But it clearly hasn’t been enough to bring about change. It also tends to emphasise need (epitomised by the infamous ‘wrinkly hands’ photo), which can sit uncomfortably with a more strengths-based sector.
  2. Rights-based: ‘Older/disabled people have a right to independence’. In a strengths-based sector, this often feels like a more righteous (literally) argument to make. But does it work any better with the public and policymakers who ultimately decide whether reform happens? I’ve seen nothing to suggest it does.
These arguments have been insufficient, I think, to overcome reluctance from people – not just governments – to bear the extra costs that reforming social care entails. That may be changing: some polling suggests greater public enthusiasm for higher public spending. Still, it’s noticeable that no local authority has been willing to put public mood on social care to the test by calling a referendum on a significant increase in council tax. The reason is simple: they think they’ll lose.

 

The limited impact of these arguments has not led the sector to fundamentally change or augment them but instead to say them MORE LOUDLY AND URGENTLY. That’s led to a third type of argument.
  1. Crisis! Everyone is familiar with this argument. ‘The sector is at tipping point’. ‘Care homes are going to collapse’. These crisis messages are understandable and have worked, up to a point. They have led government to drip feed the sector with money. But it’s only been short-term funding, not wider reform. There’s little reason to believe that will change.
There are three arguments that have been less used.
  1. Self-interest. Stephen Chandler used this a recent King’s Fund event when he said: ‘We are all just one lifechanging incident away from needing adult social care’. It is powerful and has the benefit of moving away from ‘them’ and ‘us’ view of disability and social care, though a weakness is that most people still don’t think they’ll need support (or are willing to take the risk they won’t).
  2. This argument is enticing: social care funding is not really spending money but investing in growth. Skills for Care has done some work setting out this economic case and it has merit. But it has weaknesses. If growth is the main goal, other areas will claim as much or more benefit from investment as social care (education for example). So while the economic argument has been under-developed, on its own it is again unlikely to convince a sceptical Treasury. However, it’s an example of the type of argument that we should develop more: the instrumental argument.
  3. Instrumental. The question here is: what are the broader policy goals that social care reform might help deliver? There are at least three issues that are worth further exploration. First we should look at social care in the context of wider workforce policy. One of the prime reasons that reform eventually succeeded in Japan was because provision of more social care was seen to fit the broader goal in Japan of enabling more women to return to a dwindling workforce. With Brexit, it is possible we will be in similar territory. Secondly, the prevention agenda and in particular the ‘grand challenge’ on ageing. The government has set an ambitious target to ensure that people can enjoy at least 5 extra healthy, independent years of life by 2035. Social care ought to be a key player in this, yet is barely discussed. Finally, ‘levelling up’. Here again social care ought to be considering the case for investment in social care as an agent of social, political and economic change. These three are by no means an exhaustive list (and nor should we be shy of making the case for social care as a contributor to the NHS as part of this argument).
These six arguments should be seen as complementary to each rather than alternatives. Some will work better than others with some audiences and in some scenarios. But together they could be brought together as a credible case for change. That might not in itself be enough. There are other, underlying problems to resolve:
  • We need to be clearer about the tangible benefits that investment in social care is buying. This is one of the reasons social care tends to be at the back of the queue for funding.
  • We need a clearer sense of national political accountability for social care. There has been unwillingness by national politicians to invest political capital in reforms over which they have limited control in delivery.
All of this means the sector would still have to improve its evidence, its messaging and its discipline. Nevertheless, if the social care sector continues in the same way it will likely get the same results: this offers at least some initial thoughts on how the future might not follow the same path as the past.

 

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