By Alan Rosenbach
Social Care has always been and always will be political and so
about money and power. To see how we might shape the future for
social care we best understand the recent past. "The rise of the
welfare state in the late 19thCentury was in response to the
growing popularity of left-wing politics, especially among the
working class. Conservatives and Liberals in the late
19th early 20thcenturies could see no greater threat to their
political position than that posed by socialism".
The socialist aims were for a much greater role by the state in
tackling poverty, poor health and inequality between rich and poor.
The response by the ruling elites was to cede ground on meeting
health needs in the early 20th century through voluntary
hospitals meeting acute care needs and a means tested pension for
older people by 1908.
Then, as now, the majority of carers were family members looking
after their older or disabled relatives. We should not romanticise
this idea. High rates of death in children, families moving away,
immigration and war meant many disabled and elderly people had no
Left-wing politics in the middle of the 20th Century
shifted the debate from the deserving and undeserving poor to the
setting up of the National Health Service, free at the point of
use, and the National Assistance Act at the same time in 1948,
which means tested social care. The concept of the state supporting
you from cradle to grave was established. So successful has this
system become that we are all living longer, which may or may not
be a good outcome.
We have learnt along the way that support in or closer to
people's homes and in communities rather than in institutions leads
to improved health and well-being. We have shifted from local
government running services to the development of less than perfect
public service markets for care and support. We shifted from:
- Professionals deciding what is best to
- Central government targets to
- Voice of the consumer to
- Choice of the person using service
being the driving factor in market design. Voice and choice are
still somewhat limited and there is a gap between rhetoric and
reality. We have the not-for-profit sector, the public sector,
voluntary and private sector all contributing to care and support.
There are debates about small being beautiful, particularly if it
is not-for-profit, versus large being less than satisfactory,
particularly where the for profit sector is the provider. These are
features of imperfect public service markets.
So, what of the future for social care? It looks bleak not least
because we would need to double run the funding of care and support
from the 'as is now' to where 'we want to be'. Unfortunately, 'we'
don't have a consensus about where we want to be and how we might
get there. I have great faith in experts, but we don't have a
determined evidence base about what works best for older people's
support or for working age adults in terms of service configuration
and interventions, or a requirement where we do have the evidence
that these must be implemented. We also have a significant problem
with workforce shortages.
Let's scenario plan here in summing up. We are designing a
sustainable system for care and support that would help us to shift
from our current broken system to one that works for individuals
and families. What do we need?
Funding a care and support system that is:
- Funded by general taxation for working age adults;
- Funds through general taxation dementia care;
- Funds through general taxation end of life care;
- Abolishes the role of local government as a conduit for
- Makes financial resources directly available to citizens
through the benefits system;
- Extended investment relief for companies developing new
technologies including artificial intelligence capability to
improve care and support;
- Enhancing tax and housing benefits specifically for those
choosing a career in care and support;
- Defining and implementing integration between health and care
where the evidence supports an initiative of this type.
We have regressed back to the idea of the deserving and
undeserving poor and we have come to see the welfare state as a
burden. We have allowed the poor to carry the burden of economic
failure, privatised the profits and nationalised the failures in
economic policy. The most recent analysis of satisfaction with
social services makes for grim reading. Satisfaction was 23% in
2017. The change from the previous year was not statistically
significant. At the same time, dissatisfaction with social care
services increased by 6 percentage points in 2017 to 41%.
What might services look like that meet need?
There are today aspects of care and support that meet the needs
of individuals, families and parts of communities. These are all
predicated on managing the asymmetry of power. In these
circumstances, the state and its institutions are prepared to cede
power determinedly and purposefully back to the individual, the
family and communities. Importantly they come in all shapes and
sizes. This series of blogs have highlighted the work of Community
Catalysts, Shared Lives Plus, Local Area Co-ordination and
community well-being teams. I know from my experience of working
with the voluntary and for-profit sector that these services too
cede power away from the staff to individuals.
Social care must find a coherent and articulate political voice
that spells out the inequities of the asymmetry of power between
state its institutions and citizens; highlight the positive
approaches of services ceding power back to communities. It must do
so in such a way that it threatens the status quo and so drives the
Richard J Evans, The pursuit of power; Europe 1815 -1914.
Kings Fund: Public satisfaction with the NHS and social care in
2017 Results and trends from the British Social Attitudes
By Alan Rosenbach
has been developed to create a space, including a gathering in
November, for a wide range of people and voices to debate and take
action for a positive future.
We want to get past just thinking about stabilising the
current system which isn't fit for the future. We want to make a
contribution to a much more positive vision, share what's going on
now that helps get us there, and find ways of supporting each other
as we build the future.
In Control is part of the informal group supporting
#socialcarefuture and as part of this we are hosting this blog
series. Many people will be blogging and their views are their