Social care would not be the perennial problem it is if only Britain really had a National Health Service. The NHS bears the flaws of its birth. It was designed for the society of 1948, on a model of treat and cure, at a time when most people died relatively young, of an injury or a contagious disease. The most important setting for care was the district hospital. Over seven decades, Britain has progressed from the need for hospital care to the need for social care. For a decade it has been the damaged and untouched public service. Now Boris Johnson is threatening another attempt to fix it.
There is no question that social care is in a dreadful mess. The pandemic has had a devastating effect, but even before that there was a serious but simple problem. In a country with an ageing population, demand has grown while supply has contracted. The King’s Fund think tank found that, in 2019-20, local authorities received 1.9 million new requests for support, a rise of more than 100,000 on 2015-16. Yet council spending on social care is now 3 per cent lower than it was in 2010. It is rare that public service problems are only about funding, but in this case money makes a significant difference. Age UK has estimated that 1.5 million people in England do not receive the care they need. This is not least because there are huge staff shortages, with about 112,000 vacancies at the last count.
The government confirmed on 7 September that the source of the necessary money will be an increase to National Insurance contributions, breaking a manifesto commitment and making trouble among Tory MPs. The problem with National Insurance is that it is, in effect, a levy on work. The low-paid workforce of the social care sector, who can scarcely afford further raids on their wages, will be paying a little bit more for the upkeep of their own jobs. It is not just ideological aversion to tax increases that is causing consternation among Tory MPs. Rises in National Insurance are the least progressive of tax rises and, in the topsy-turvy politics after Brexit, this really counts with some of the Tory vote.
Social care is, like tuition fees, an arena of policy made explosive by politics. Ever since the Cameron government commissioned Andrew Dilnot to look at social care in 2011 and then ignored his conclusions, the political imperative to do nothing has prevailed over the obvious need for action. Whenever Labour politicians have suggested taxing the estate of the deceased to recoup the costs of life, they have been mocked for proposing a death tax. Theresa May’s similar proposals for funding social care helped to deprive her government of its majority in 2017. Social care seems to come with a sign attached reading: “Do not touch.”
And indeed it is, conceptually, difficult. The need for social care is capricious. Not everyone will contract a long-term condition. Not everyone will need the service. Why is it fair for one person’s life savings, usually in the form of housing assets, to be depleted and for another’s to be passed down through the family, when the only difference between the two people is that the former has been so terribly unfortunate?
That seems like punishing the ill, which is why the proposal to use unmortgaged property assets to pay for the costs of social care is so unpopular. The problem is not that it is wrong, per se, to use money accumulated in the middle years of life for the travails of the end, but that it seems unfair that I should be afflicted with costly dementia while you remain fine, rattling about in your grand house.
It is often instructive to consider policy problems freed from political limits. Imagine the whole service redesigned to meet the demands placed upon it now rather than those of 1948. A modern NHS would have three concentric circles of care. In the narrowest circle we would place the core of standard medical care – disease treatment, accident and emergency, and surgery.
The middle ring would be about managing long-term conditions. Much of what we call “social care” today would sit in this part of the NHS. This would blend social care with the work of NHS outpatient services. At present, the funding arrangements are a criss-crossing mess and much of the burden gets thrown back into the NHS because of the inadequacy of the social care provision. The idea of “social care” as such ought to be abolished; this should be a single system.
The third circle would encompass lifestyle support: adapted housing and physical activity. This is the “social” element of social care, which could prevent the need for medical treatment.
This would require a government with imagination, money and time, and the Johnson government has none of the three. What we have is a compromise in which people in work today pay most of the cost of people who have retired. The most important feature of the Tory vote is not that it is unexpectedly northern but that it is increasingly elderly. This is a patching-up job. Johnson will now be sent out to convince the country that he has solved the social care problem, in the hope that nobody notices nothing much has changed.
The policy change we really need requires the consent of the people. It needs time, consideration, persuasion. What we have instead is a fix, because that’s politics.
This article appears in the 10 Sep 2021 issue of the New Statesman, The Eternal Empire