This article forms part of the LGA think piece series 'Towards a sustainable adult social care and support system'.
The last twenty years have seen at least five independent reviews of social care funding and twelve white papers, green papers and consultations of one kind or another under five governments. It has been a story of delay, dashed hopes and disappointment so the latest postponement of the next Green Paper should come as no surprise.
So why does England continue to struggle while many other countries have successfully implemented major reforms? Why have previous attempts failed and what lessons can we learn?
Here is a starter for nine:
Ask the right questions
A sustainable funding settlement requires answers to at least three basic questions - how much do we need to spend? How should the costs be shared fairly between individuals, families and the state? Where should the money come from to fund all parts of the system? Instead of a comprehensive plan, reform has usually proceeded with just one set of proposals for one part of the problem. The Dilnot proposals were a well-crafted response to the question of protecting people from catastrophic costs, but they floundered when it became untenable for the government to spend £6b over five years in resolving that issue but with no answer to mounting pressures on core local authority budgets.
Get the timing right
The glaring lesson here is that whilst election manifestos can be a good way of galvanising a high level commitment to action, general elections are very bad times to float specific proposals, especially if they raise the spectre of people having to pay more. As we saw in the 2010 and 2017 election campaigns such proposals quickly became weaponised politically, with informed discussion quickly descending into name-calling and poorly understood sloganeering.
Aim for cross-party cooperation…not consensus
If the last twenty years shows nothing else, it is surely that no one government can achieve lasting reform on its own. If Labour with time (thirteen years), money and a big majority couldn’t do it, prospects under current political and fiscal conditions look bleak. Pragmatic cross-party agreements are deeply discouraged by our ‘first past the post’ voting system. In the current febrile political climate, achieving a cross-party consensus is improbable. In the short term cross-party co-operation is a more realistic ambition than consensus – getting agreement to some principles and a process for a way forward, and ideally a suspension of party political warfare so that each other’s ideas can be a given a fair hearing.
Tackle poor public awareness of the current system
The public are generally unaware of the likelihood that they will need social care, how much it would cost and the extent of their financial liabilities under the current system. Many believe mistakenly that social care is paid for like the NHS. As long as the public view the issue from behind a veil of ignorance, it is easier for national politicians to trade on fear and misinformation when opposing their rivals’ proposals, vividly demonstrated by so-called death tax row in 2010 and the dementia tax row seven years later. This explains why proposals that represent a genuine improvement, for example the Conservative’s proposals in last year’s election manifesto to lift the means test threshold to £100K, was greeted by many as an outrageous new incursion into private assets.
Don’t begin with the hard stuff
In recent years the policy debate and public discussion of social care has focused almost exclusively on the money issues where the choices are deeply contentious, notably the totemic example of whether people should be expected to use their housing wealth to pay for care. This approach has been entirely back to front, with little preceding effort to engage the public (noting the previous point) about what kind of social care system do we need in the 21st century, what form it might take, who would benefit, what it might cost. The ‘Big Care Debate’ in 2009 attempted to carry out this essential groundwork but ran out of time.
Paralysis by analysis
Bookshelves groan under the weight of twenty years of policy reports, analysis and reviews from governments, charities, think tanks and academia. A whole range of policy options have been identified and analysed.
Arguably we have spent too much time considering policy content – the ‘what’ of social care reform and too little time on policy process – the ‘how’ question - how we secure sustain political agreement to see through sustainable reforms.
Action, not more analysis, is surely the priority now.
Take a long term view
England’s traditional approach to social care reform has been a succession of short term, ad hoc initiatives such as the Better Care Fund and the social care precept. Counter-productively this may have helped to prop up a failing system that is crying out for transformation. In contrast, countries that have successfully introduced major reforms have taken a much more long-term approach, planning and implementing changes over a number of years, sticking with them and making adjustments along the way.
A long-term approach recognises the scale of the implementation challenge and affords flexibility over the economic and political cycle, nothing that the state of public finances will change over time, as will household income and wealth profiles. We will need a different settlement, with an adjusted mix of funding sources, for different generations.
Make a positive case for change
The usual narrative around social care reform has been unremittingly negative – the language of demographic time bombs, the financial burden of care on the tax payer, a threat to our personal savings and assets, even the roofs over our heads. It is hard to galvanise public support and political commitment for change when social care is portrayed as an overwhelmingly negative problem that is just too difficult to address.
Again we can learn from other countries in developing a positive case for change that stresses not simply the costs of a better system but the benefits to individual and families; and the value of investment in social care as part of wider economic and social objectives. Japan, for example, made their new social insurance arrangements deliberately generous to attract public support. Australia’s reforms were rooted originally in concerns about national productivity. The Government’s industrial strategy acknowledges the importance of social care to the economy and offers an opportunity to tell a different story about the value and benefits of good social care and not just its costs.
The pressures on the social care system are now so great that impatience for immediate change is understandable. But the journey from the current system to the one of our dreams is not going to happen any time soon. Genuine reform will take years to achieve so all parts of the sector – local government, providers, charities and user organisations have to be realistic in our expectations - after twenty years of waiting this shouldn’t be too difficult. Parts of the sector will need to exercise restraint in resisting proposals because they don’t solve everything, for everybody, all at once.
In short, there will be little point in producing yet another green paper without understanding why previous efforts have failed and drawing on the experience of other countries that have achieved greater success. The choice now is to learn from history or simply repeat it.
Richard Humphries, Senior Fellow, The King's Fund