On Wednesday, hot foot from the Palace where he had just been appointed Prime Minister, Boris Johnson said:
“My job is to protect you or your parents or grandparents from the fear of having to sell your home to pay for the costs of care.”
“And so I am announcing now - on the steps of Downing Street - that we will fix the crisis in social care once and for all with a clear plan we have prepared to give every older person the dignity and security they deserve."
What does this mean?
If you take these words at face value they seem to be the stuff many social care campaigners’ dreams are made of. Here is an incoming Prime Minister promising to sort out social care for good – not just mentioning it as a footnote but apparently putting it at the centre of his domestic policy agenda (though admittedly his foreign policy agenda rather dwarfs it). After the last two plus years in which Prime Minister May’s consultation document on the future of social care was delayed so many times I literally lost count, the degree of certainty in this statement is refreshing. Although no timescale is specified he is setting the bar high in terms of the positive impact he says his administration will make on care, at least on some interpretations of these words.
And yet – as social care campaigners we have been let down so often before. We have been marched up the hill only to march down again over and over again, with the non-appearance of the Green Paper just the latest in a long line of set-backs. Veteran social care watchers such as Richard Humphries of the Kings Fund can recite Commission after Government Paper that governments of all colours have asked for in the last ten to fifteen years, only to baulk at taking any meaningful action on the back of them, usually because the political and/or economic cost was deemed too high.
Time for change?
Will it be different this time? Accustomed as we are to disappointment, we are quick to see the problems in what Mr Johnson said.
As a starting point, in this and in other comments he has made in recent days and weeks, social care is defined purely in terms of the needs of older people. Of course, they are an incredibly important part of the care agenda, but not all of it. About half of council spending on adult social care goes on helping disabled people of working age and those with chronic illnesses, such as MS or MND. There can be no viable solution to the challenges facing social care unless it ensures all these people get a good service that meets their needs. In addition, there are millions of informal, unpaid carers whose fate is intimately tied up with that of the person they care for, whether the latter is older or younger. Their needs have to be recognised and met as well.
It may be that Mr Johnson and/or his Ministers know this very well but that when making a speech such as the one yesterday, for political purposes the emphasis has to be on ‘age’ because this ‘cuts through’ to the general public most effectively. Still, it is hurtful and arguably rather insulting to these really large and significant groups of our fellow citizens to appear to be overlooked – and not for the first time – and it would be completely unacceptable if this is what actually happened in practice with any proposed plan.
But secondly, the emphasis on older people is drawn very narrowly, and incorrectly in many experts’ view. Most people who know about care would not define the ‘crisis’ it faces as being principally about the fact some older people or their families have to sell their homes in order to pay their care bills. This is not to underestimate the pain which this must provoke but rather to observe that there are other problems with the current state of care which are arguably just as bad, if not even worse.
For example, 1.4 million older people have at least some unmet need for care, among whom several hundred thousand have multiple unmet care needs, to the extent that one really does wonder how they manage at all. As demand for care has progressively outstripped what diminishing amounts of funding can supply, more and more older people – and disabled adults too – who would once have qualified for a State provided service have been screened out. Some are fortunate and have friends or family who can step in, or they have enough money to buy a decent service – and there is one to be had locally – but none of these are givens and many older people are simply under-catered for in terms of their care needs, for one or more of these reasons. The same is also true, of course, of many disabled adults. This diminishes their lives and can undermine their health and capacity to live independently on their own terms.
Nor should we forget the plight of many older and disabled people who have seen their agreed care packages stripped back in a desperate effort by their council to spread the jam more thinly. A survey carried out by the Care and Support Alliance last year found numerous examples of this, as witnessed by social workers as well as users. Or the position of those people who are receiving only rushed, rather tokenistic care or whose only choice is a care home rated as requiring significant improvement – there is arguably a crisis of quality too, certainly in terms of consistency.
A crisis with the care process
There is also arguably a ‘crisis’ with the ‘care process’, the starkest example being the fact that since the Green Paper was promised and not delivered, more than 50,000 older people have died waiting for a care package to be put in place. No one can say how many of these people might have lived longer had they received care sooner, but at the very least their final weeks and days would have been more comfortable and their families better supported. Make no mistake, good, skilled care of all kinds not only enhances lives, it saves them too.
The reasons for these delays vary from place to place but include the fact that many councils are overwhelmed, given the inadequate resources they have been granted by central government in recent years. A further factor is that in some areas there is literally no care to be had. This is itself a kind of ‘crisis’ I think; the fact that we now have ‘care deserts’ in some parts of the country. These are typically rural areas or affluent towns where there are other occupations that pay better, with less stress, than working in care. As a result it is impossible for providers to recruit and retain enough staff to meet local need. The result is insufficient domiciliary care, understaffed care homes and rocketing care prices.
A care workforce shortfall
In addition, surely the fact that on any one day there are more than 100,000 vacancies in the care workforce is a ‘crisis’ of sorts too? And that some 8,000 people had their care disrupted last year because their care provider went out of business, leaving them high and dry and needing to be transferred to someone else?
The list is long, demonstrating that the problems in the care system are many and multi-facetted, though most have the chronic lack of sufficient funding, over many years, at their heart. However, this means that if Mr Johnson’s government is to achieve the goal he has set, it won’t be nearly enough ‘just’ to create a situation in which people no longer have to sell their homes to fund their care.
So what’s the plan?
An additional cause for worry in Mr Johnson’s words, at least among those inclined to gloom after so many disappointments, is the idea that “there is a clear plan [they] have developed”. What’s that? The Green Paper? A project that passed through so many official, adviser and Ministerial hands over more than two years that it is hard to believe that what’s left is a great piece of work that truly hangs together? Or is this some new plan, perhaps developed in the last few weeks by Matt Hancock, the Secretary of State who – unusually in this new government – has retained his role and who reportedly helped plan the ‘transition’ of Mr Johnson into Number 10?
If so, judging from what Mr Hancock has said before, such a plan could take one of several forms; it could be based on auto-enrolment, for example – an idea that works well for pension saving, but which most commentators think is unlikely to do so for care and/or which could undermine pension saving into the bargain. Moreover, if you believe – as I and many others do too – that the solution for social care lies in us all ‘pooling the risk’ of developing care needs, much as happens with the NHS regarding health needs, then auto-enrolment isn’t enough because people can, and no doubt substantial numbers would, opt out.
Or, as one or two newspapers are suggesting, it could be a scheme based on people being encouraged to buy their own insurance, to protect just themselves from this risk. If so this is even further away from the ‘risk pooling’ principle, and even less likely to make much difference. It’s a racing certainty that most people would not bother to buy this insurance – which currently is not even available in the marketplace. Why should they? After all the risk of developing care needs is actually rather low, which is why ‘pooling’ that risk through small compulsory contributions of some kind over a long period of time is the obvious thing to do. A voluntary insurance approach to funding a good social care system does not work anywhere in the world at the moment, so there’s no reason to think it can here.
Or, more optimistically, it might be a plan based on the consensus apparently emerging from Left and Right leaning think tanks and other opinion formers in recent months – that of pooling care risks, as described above, and making care free at the point of use – as happens in Germany and Japan. Jacob Rees-Mogg has personally endorsed one such scheme, advanced by Policy Exchange, and even mentioned it on Thursday in his first outing as Leader of the House of Commons.
Given the ideological position of this administration it is unlikely that the essence of Mr Johnson’s plan will be ‘free personal care’, as happens in Scotland and is usually viewed as a Left of centre idea, but arguably this is a variation on a broader theme anyway; the two key principles already mentioned of ‘free at point of use’ and ‘risk pooling’ are really the lynch pins in my view.
Or, finally, is it possible that there isn’t a proper plan yet at all, that Mr Johnson was being a bit economical with the truth there? Perhaps he felt this would add conviction to his statement and that the detail remains to be hammered out to fulfil the ambition which has now clearly been articulated?
I hope so. Surely, one of the lessons from the ‘dementia tax’ debacle that befell the Conservatives at the 2016 Election is that it is a mistake to let exceptionally clever policy wonks, however well politically informed, to come up with a plan in secret, without testing it on a wide range of audiences, including people who receive care and who provide it, as well as those who otherwise have insight into all the real world issues that inevitably arise and how different groups among the public are likely to be affected and may respond. While an agreed way forward cannot come too soon from the point of view of many users and would-be users it feels important for this Government to take enough time to make the most of the opportunity that now exists.
The political commentators are mostly saying that the driver for this pledge is the need to resolve ‘difficult issues’ like social care before an early Election that might be called later this autumn, to avoid ‘dementia tax two’ all over again. If so, let’s all hope that the urgency works to the advantage of social care for once, and not against it. After all these years of false starts it’s about time we had a slice of luck.