The lives we want to lead: where next for the debate about care and support reform?

Last year we published a report on the future of adult social care and support.

‘Towards change, towards hope’ restated the case for reform, highlighting long-standing issues on which action is needed, including funding, workforce, unpaid carers, providers, unmet and under-met need and the relationship between care and health. 

Building on our 2018 green paper - 'The lives we want to lead', the report also stressed the need to change the way we think and talk about social care. We suggested that although it has its place, the ‘crisis narrative’ typically associated with social care in recent times has become too dominant.

Further, we agreed we needed to move away from thinking about social care in transactional terms and focus more on its value in supporting people’s relationships and, in turn, our local communities. In short, we stressed the importance of telling a far more positive story about social care and support.

The report was published on 6 March and made no reference to the coronavirus pandemic. On that day, total COVID-19 cases in the UK stood at 160 and two people had sadly died.

The severity of the pandemic and the resultant upheaval and change in our daily lives since then has been staggering. Yet, while it may feel like everything has changed, some things have not.

The issues facing social care – particularly the scale of funding pressures - are just as pressing, with many having been exacerbated by the pandemic. 

In this respect, the 2020 Spending Review provided some, but not enough relief, and the 2021 Budget was notable for its absence of measures to support social care in the short or long-term. So too has the value of social care to people’s wellbeing remained at the fore. 

What is different is that these two defining features of social care – its challenges and its value and potential value have been revealed to society at large in a way not seen previously. We therefore hope this is no longer a debate limited to people who use or work in social care and its broad range of interested parties. 

Instead, we hope it is a conversation taking place in people’s living rooms as we all witness the impossible circumstances facing people with lived experience of care, care providers, their workforce, councils and the many others involved in supporting people to live their best life.

More importantly, we hope those living room observations of the ‘impossible’ might also help plant seeds of understanding what could be possible if our model of care and support was the best it could be.

Such moments of national interest can be galvanising and lay the ground for action. On the flip side, they do not come around often and the history of failed attempts to reform social care are also testament to what happens when a policy priority is not a public, and therefore political priority.  

There are some signs this is changing. In many ways, the pandemic has revealed our instinct to care about each other. And if ‘social care’ is, in one sense, simply a more formalised system for caring about each other, it too has demonstrated its core values of compassion, kindness and humanity.

That has resonated with people; by its end, the ‘clap for carers’ was clearly a ‘thank you’ not just to the NHS but to all those people involved in supporting other people’s wellbeing. That may suggest the beginning of greater public momentum.

There is also political momentum. In various All Party Parliamentary Groups and Select Committees, parliamentarians of all parties are highlighting the need to address the challenges facing social care, both now and in the longer-term. The same appears true in Government, with the Prime Minister having acknowledged the difficulties facing social care and the need to “care for the carers as they care for us”. 

Underpinning much of the political narrative is the idea that lessons need to be learned from the pandemic and applied to the future so that we do not simply return to the status quo. And so, we hear of the pandemic as a ‘trigger’ or ‘catalyst’ for something different; a moment that accelerates lasting change in our society.

As the Government considers what those different changes might look like, social care and support must be prioritised: repeated promises of action are one thing; now it is time to deliver.

The question of the lessons that need to be learned from the pandemic are central to the LGA’s recent thinking on the future of social care. 

For example, it was behind our work on the ‘seven principles for social care reform’ in July 2020 which was supported by more than thirty prominent national organisations. It was also the motivation for five roundtable discussions on social care reform that we convened with colleagues from across the sector last summer. 

Broadly, these considered what the future vision for social care should be and what needs to be done to turn that vision into reality. 

The LGA operated purely in ‘listening mode’, giving the floor entirely to participants so they could share their thoughts and experiences from their part of the social care world and their interaction with it. 

To ensure all such views were given ample and focussed time the roundtables were arranged thematically as follows:

• Local government (Solace and ADASS)
• Care providers (Care Provider Alliance)
• Health (NHS Confederation)
• Voluntary, community and charity sector (Care and Support Alliance)
• People with lived experience (Social Care Future)

We are extremely grateful to colleagues from the organisations mentioned who kindly gave up their time to co-chair the roundtables with us. We are also extremely grateful to colleagues from the King’s Fund who provided valuable introductory remarks at the start of each meeting.

The roundtables totalled more than ten hours of discussion and it is impossible to do justice to the richness of the conversations. This report therefore, sets out some of the key points made by participants. 

In some cases, these were common to all the roundtables, in others they were common to the particular grouping of colleagues. In addition to areas of convergence, there was also divergence of opinion. This was just as valuable as identifying areas on which there was a shared view. The insights are thought-provoking, honest, challenging and inspiring. 

What shines through most brightly is the idea that, collectively, we have perhaps lost our way a little on social care. For multiple reasons and with no blame attached, the person – the whole person in their complex and unique entirety is not fully seen and is not front and centre. Instead, it is systems and the serving of their bureaucracies that have tended to have primacy. 

In delving deeper, what emerged in all discussions was a linked idea that social care currently suffers from a lack of trust. Whether the conversation was about national and local government, commissioners and providers, health and social care, the voluntary and community sector, or people who draw on care services and the public sector they have to interact with - ‘trust and respect’ came up time and again as a central issue that needs to be addressed. 

For the avoidance of doubt, we are not saying there is a complete absence of trust, nor that systems do not matter or that there are no examples of great and innovative social care. 

And for all the soul-searching of what is holding social care back, there was an equally powerful and motivational sense of what is working well and what would be helpful to replicate on a grander scale. 

Rather, the point is that in thinking about the future we need something notably different to what we have today, and that difference should be built on a greater sense of trust between all the different people who draw on, work in and interact with care and support.

We do not pretend this is easy; adult social care is complex and involves a range of different partners each with their own priorities and pressures. But the pandemic has been notable for helping to reinforce the common purpose and shared endeavour that unites everyone connected to social care. It has also reminded us of, and reinvigorated, the pride we feel in the value of social care. This is something to hold onto.

The key points presented here provide valuable insights. The ‘LGA perspectives’ that flow from them are our reflections, building on all the work we have done on the future of care and support, particularly since 2018 and our own green paper, The lives we want to lead.

We hope this report will be of interest to all those people, the public included who have an interest in bringing about a better model of care and support for the future; one that is person-centred, provides choice and control and, above all, supports people to live the life they want to lead.

As above, colleagues from the King’s Fund kindly attended all five roundtables to provide helpful context to the debate about the future of social care.

They set out eight challenges facing social care and how these have been impacted, or not, by the pandemic. The following is a summary of these points, taken from a long-read article on social care on the King’s Fund website. 

Social care’s key challenges

• means testing: social care is not free at point of use like the NHS
• catastrophic costs: some people end up paying large amounts and even selling their homes to pay for care
• unmet need: many people go without the care and support they need
• quality of care: a wide spectrum of concerns, from 15-minute care visits to neglect and lack of choice and control
• workforce pay and conditions: staff are underpaid, leading to high vacancy rates and turnover
• market fragility: care providers go out of business or hand back contracts
• disjointed care: health and care is not integrated around the individual and causes issues such as delayed transfers of care from hospital
• the ‘postcode lottery’: there is unwarranted variation between places in access to care and its quality
• social care’s challenges in light of the pandemic.

The emphasis on these eight issues has shifted – the first two have barely been mentioned during the past few months. Instead, the public focus has rightly been, first on quality of care, as Covid-19 wrought a terrible death toll and in many places fundamentally changed the way care was being delivered. 

Second, there has also been some though arguably not enough focus on unmet need, as COVID-19 both created more need and made it more difficult to meet existing need. 

A third key area during the pandemic though one that has had less attention has been the difference in the ways local care systems have dealt with the pandemic and the potential consequences for the existing postcode lottery of access and provision.

Two more areas highlighted during the pandemic have been the sector’s workforce, which has received more recognition than ever before but is still underpaid and to its providers where the pandemic has exacerbated market fragility.

And finally, the relationships between services, which even under normal circumstances can lead to disjointed care – have been at the forefront during COVID-19, most obviously in the ongoing dispute about discharge from hospital during the early stages of the pandemic.

The social care and support ‘sector’

Many participants reflected on the perception of the social care sector by Government. It was felt that the sector is likely to be seen as fragmented, which has two main consequences:

• It can leave Government feeling like they do not have sufficient levers over social care (which has consequences for accountability and transparency, such as we have seen in the health and care white paper).
  
   
• It tends to lead Government to view social care through an NHS lens and prioritise those elements of social care that have the biggest impact on the NHS.

There was widespread agreement amongst participants that ‘speaking with a single voice’ is crucial. However, it was recognised that ‘sectors within sectors’ can themselves be fragmented and that the price paid for an overarching set of key messages that the sector is comfortable with, can sometimes be a more diluted version of those messages.

In other words, consensus achieved on a lowest common denominator basis can often stifle the boldness of messaging that is perhaps needed.

In considering how the debate about the future of social care tends to play out, and needs to play out, there was an interesting difference of opinion.

Some participants suggested that the sector can often over-intellectualise the debate, neglecting the “emotional case for reform”. Others thought a balance was needed between “detail and emotion”.

The divergence of opinion was considered by some participants to be a result of people’s different aspirations for reform, themselves shaped by different interpretations of ‘fairness’, which is so often at the heart of the reform debate. 

Some participants also noted that, as helpful as they are, principles and vision statements need to sit alongside a clear articulation of how a particular principle or vision will actually be delivered. 

This idea aligned with a broader view common to many roundtables that much of what is needed for a debate about the future of care and support has already been done; the challenges have been identified, so too the solutions and their pros and cons – what is missing is real action.

The question of lessons learned from the pandemic underpinned all the roundtable discussions either explicitly or implicitly and run through this entire report.

However, certain points stood out and are worthy of mention here. 

First, there was a sense from several roundtables that the pandemic demonstrated a continuing lack of understanding by government of social care’s value and how care and support works.

This was felt to be particularly true in terms of the Government’s understanding of both the breadth and depth of the provider sector, and the essential importance of the voluntary, community and charity sector, whose status as a ‘third’ sector is unhelpful and unrepresentative of the central role it plays in local communities. 

The issue of perception and language was also picked up in respect of the term ‘vulnerable’ to describe people who use social care services. This was felt to be deeply unhelpful as it appeared to define people solely in terms of their needs, creating an equally unhelpful sense of ‘them’ (the ‘needy’) and ‘us’ (the ‘needed’).

Another observation common to several of the roundtables was that the full consequences of the pandemic are difficult to fully understand at this moment in time.

For example, participants talked about people who have been pushed into poverty for the first time, increases in unmet need and a rise in mental health issues (caused in many cases by increases in loneliness) – all of which are difficult to accurately quantify but will almost certainly increase demand for services and exacerbate inequalities. 

This underlying uncertainty raised further concerns about social care’s ability to plan for the future and therefore its ability to support people. It also linked to a widely shared view that the pandemic has thrown into sharp relief the consequences of a historic failure to act on the social care workforce, especially in respect of pay, skills, training and progression. 

There were also positive lessons to be learned from recent months. Participants in several roundtables highlighted the speed at which systems were able to change, challenging the validity of the historic ‘we’ve always done it this way’ explanation for why change is neither possible nor desirable. 

Similarly, participants in all roundtables noted the powerful impact local communities had when they mobilised, for instance, volunteering and mutual aid. This reinforced the point above that all parts of the response to the pandemic, as with all parts of the response to supporting people to live their best life, are equally important.

Articulating a clear and compelling vision for social care was a priority discussion for participants in all the roundtables. In one sense, this itself demonstrates a desire for something different for the future from across all parts of the social care world.

The key common features of a new social care vision identified by participants were as follows:

Primary focus on the person: many participants noted that “transactional care” and “care as a commodity” have become too dominant a theme in defining day to day social care, particularly at the expense of a focus on the individual.

There was a clear consensus across all roundtables that the starting point for social care should therefore be people being treated fairly and equally. In this way, a number of participants suggested the need to drive home the message that social care is about people’s human rights and is therefore a moral imperative.

Seeing the whole person: participants were clear that a primary focus on the person will only be of value if the whole person is seen. This means moving away from the practicalities of eligibility and the process of deciding ‘who gets what?’ and starting with the question, ‘what do you want to achieve and how can we help with that?’ 

It was felt this would help shift the focus from simply ensuring certain tasks are administered (characterised as ‘maintaining a life’ eg washing and dressing) and toward social care’s wider role in supporting people’s relationships with friends, family and their local community (characterised as ‘living a life’).

Control, choice and co-production: with the whole person front and centre, all roundtables articulated variations on a theme in respect of people having choice and control of their care. There was also consensus that these ideals need to hold true for all people; older people, working age adults and unpaid carers.

Underpinning this approach, participants across the roundtables highlighted the need for more coproduction, “turbo-charged at the local level”, with people being given a proper and meaningful voice in decisions about both their own care and the way in which social care works at a more strategic level, based on respectful acknowledgement of people’s own expertise. This was also considered to be important for embedding greater accountability to people who use services.

Trust: a dominant theme in discussions, and linked closely to the above points, was the need for greater trust within social care. Several participants noted that the “commodification of care” has given rise to a system that “follows the public pound”.

While it was recognised that accountability for public funding is important, participants suggested that such a system breeds an onus on compliance, which in turn can result in mistrust. It was felt that a genuine focus on people, seeing the whole person and embedding control, choice and coproduction, could go a long way to fostering and sustaining greater trust within the relationships inherent in social care.

Workforce: participants across all roundtables were clear that a new deal for the social care workforce needs to be a central feature of a future vision for care and support. An “informed workforce” – fully aware of the principles of personalisation and people directing their own lives – was also seen as a key vehicle for building mutual trust and relationships within social care.

Health: the idea of place-based approaches to health and wellbeing were also regarded by many as being important to a future vision for social care, particularly their potential for helping to embed a greater emphasis on prevention and early intervention. Participants noted that glimpses of this have been evident during the pandemic, raising questions about the role of the state (national and local) in creating the conditions for this to thrive in the future. 

COVID-19 has inevitably raised questions about the respective roles and responsibilities of national and local government in tackling the pandemic. But such questions, in their broadest form, clearly predate the pandemic. 

All roundtable participants offered interesting perspectives on the national-local divide. Some recognised the important connections between social care and other services such as housing, green spaces and transport, cementing an idea that supporting people’s wellbeing is “hyper local”. 

Linked, other participants noted the “clear and strong links” social care has to both the prevention agenda and tackling the wider determinants of health, which again was considered an inherently local endeavour. Some participants concluded  the pandemic has shown that while  Government needs to set out national-level plans and guidance, it also needs to recognise that the local nature of  delivery is both necessary and effective.

In addition to the national-local dynamic, the relationship between councils and care providers was another key area of focus for participants. Several acknowledged councils’ strengths, particularly their knowledge of local areas and their democratic accountability, but they also highlighted key tensions within the relationship. 

At a general level, the idea of “localism at all costs” was considered unhelpful by some participants and more specifically, there were concerns amongst some participants that councils were trying to “run providers’ businesses”, “micromanage services” and “become regulators”.

These participants suggested such tendencies are unnecessary, burdensome and can damage trust between providers and councils. They also argued that more transparency and standardisation in the commissioning process would be helpful in tackling variation across the country.

Several participants talked about there needing to be no ‘one size fits all’ for local government’s relationship with health. Instead, participants were clear that integration should be fundamentally based on what works locally with clinical, professional and political leadership all pulling in the same direction on place, neighbourhood and community.

There was broad agreement on this point but it was also noted that parity of esteem between health and care was required to enable “honest conversations” about what each part of the system is good at. Parity of esteem was judged by one participant to have three key dimensions:

• Operational: at this level, relationships between local government and the NHS were thought to be improving, but the key task remained making sure that decision-making on both sides of the system is conscious of the impacts on the other and beyond
  
   
• Planning: at this level, Integrated Care Systems (ICS) were considered “an odd footprint to ‘do’ adult social care planning” as they remain fundamentally about patient flows within the NHS. However, ICSs were recognised to be better at partnership working with councils than Sustainability and Transformation Partnerships, even though they ultimately remain a mechanism for delivering the NHS Long Term Plan. For some, this led to a question about what should be driven at place level within ICSs.
  
   
• Policy: at this level, the simple but effective example was given regarding senior staffing for social care in the Department of Health and Social Care versus that for health in NHS England. The former (at the time of the roundtable) had one director for the whole of adult social care, compared to a far greater “machine” for the NHS.

Participants further noted that a structural solution will not solve the above issues and that positive change to secure parity of esteem requires the right culture and leadership, as well as more integrated teams with a mixed skill base.

Linking closely to the discussions about a future vision for social care, roundtable participants also spent a significant amount of time considering practical next steps and the types of activity to focus on, to make the case for reform. 

At a high level, participants advocated pushing for a more “radical” future, including more innovation in how people are supported. This led to a view that any discussions with Government on the future of social care need to be brought back to the value and potential of asset- and community-based approaches to support underpinned by coproduction, rather than focussing just on the cost of provision or protecting people from having to sell their home for care. 

This led some participants to suggest that part of social care’s pitch should be for transition funding towards asset-based models of care that filter out across the wider care and support sector. Evidencing the return on such investment, as well as what constitutes warranted versus unwarranted variation, should be part of that pitch, participants suggested.

In articulating the above type of approach, several participants noted that councils’ local, regional and national leadership should be promoted; both to demonstrate local government’s role in helping to achieve national priorities, but also to ensure national government does not unilaterally lay down requirements of councils in respect of social care and support. 

Participants – notably not from local government, also suggested that councils’ partners need to better understand and recognise the multiple and competing demands on local government and what they can and cannot do. This, it was felt, was part of the agenda of building greater levels of trust within the sector.

Thinking about options for reform and what the Government may or may not propose, several participants pondered what would constitute progress on the reform debate. Some took the view that “we should not let ‘perfect’ be the enemy of the good” – and that after such a long period of inaction any progress should be welcomed, even if it was part of a longer proposed timeline of change. 

Others felt that a “big bang” moment of reform was needed that tackled the multiple issues facing social care given so many of them interlink.

For some participants, this led to a question about what should be prioritised if reform developed along more incremental lines. Here there was a broad consensus that tackling unmet and under-met need should be a first order priority given its consequences for wider society, if left unaddressed. 

The same status was given to securing a better deal for the care workforce. This included more typical notions of a better deal (for example pay, career progression, training and skills development), but it also included the idea of supporting the workforce to be more flexible and creative in the way it works together with people who use services. As one participant noted: “Nobody enters social work to say ‘no’”.

The pandemic has meant something different to each of us and impacted us all in unique ways. But it has also revealed some fundamental commonalities, chief among them our instinct to care about each other.

Our partners, children, parents, siblings, friends, neighbours: we have wanted all the people in our lives to be well and safe in challenging times; we have wanted them to be able to live the life they want to lead.

Social care and support has shown itself to be an essential part of how we achieve that and it is impossible to think that this era-defining moment may pass without affecting lasting and meaningful changes to social care that so many people and organisations have been calling for over recent years. Committing to social care reform is about committing to a better future for all of us. The Government must act now.