Covid-19 has exacerbated the social care crisis – but a national service isn’t the answer
Mon 20 Jul 2020 03.26 EDT
It is a deep national shame that despite the dedication of staff, care home deaths account for almost a third of all Covid-19 fatalities in the UK.
Politicians have procrastinated over social care for years, but this is unlikely to be feasible for much longer.
Among the many calls for reform, one mantra is gaining traction: the idea of setting up a national care service. There is an obvious appeal to this. It echoes the idea of having a National Health Service, free to use and open to everyone. Subsume broken social care into a tried-and-tested national system, goes the thinking. And just as the government plans to tighten its grip on the NHS, the appeal of also trying to run social care from Whitehall might be too great to resist.
But in fact, the opposite is true. Social care is in dire need of attention from decision-makers, but nationalising it is not the answer. Instead the NHS should become more locally accountable.
At one level, the issue for social care begins and ends with money – many of its weaknesses in relation to the health service can be traced back to this. The NHS gets its money directly from government and hospitals are paid for what they do. Social care is funded by local government. As council budgets have been cut, spending has fallen, and there is no mechanism to respond to demand.
This has created a two-tier system. Every year, NHS trusts run huge deficits that are written off by the government. But until very recently, councils have been legally required to balance their budgets annually.
When NHS demand grows, hospital finance is configured to meet it. But as social care demand grows, finite resources are stretched ever thinner. People can walk into a hospital, but higher thresholds for care mean it is only available to those who need it most. NHS staff have a much better pay deal and care workers feel undervalued.
Low pay and poor recognition is forcing the care sector to operate significantly under capacity, with the 122,000 current vacancies set to be further compounded by new immigration rules that restrict overseas workers.
So the first priority, however politically difficult, is to fund social care properly.
But beyond this financial reality, there are deeper problems with a rigid national model that have been further exposed during the Covid-19 pandemic.
Instead of being a safety net of last resort in a community-based system of care and support, acute hospital provision dominates the healthcare landscape, sucking in a huge amount of funding and capacity. Without reform to shift away from crisis intervention and towards prevention, hospital budgets will eat up an ever-greater proportion of public service spend.
Setting up a national social care service risks replicating this bias. Care homes are expensive and for people with high needs. But social care is much broader than just care homes and applies to a wide range of support to enable people to live in their own homes independently. And it is not just for elderly people: almost as much is spent on support for working age adults with learning disabilities.
These facts risk being lost in any move towards a national social care service. A single service would tend towards uniform, building-based services, easily managed and monitored from a Whitehall department, rather than adaptable, community support that would vary between areas.
A national service also risks working against the needs of the very people it is supposed to support. In the early weeks of the Covid-19 crisis, the government set out two objectives – one institution-focused (“protect the NHS”) and one people-focused (“save lives”). But in the rush to protect the NHS, opportunities to save lives were missed. To free up hospital beds, elderly patients were rapidly discharged into care homes without being tested for the virus. To increase NHS capacity, Nightingale hospitals were built from scratch, while care homes were left without basic protections.
Care is essentially about people and relationships, not buildings and services. Alex Fox, the chief executive of Shared Lives, makes a compelling case for reimagining the core support relationship at the heart of public services. It is not clear whether a national one-size-fits-all care system would be capable of embedding such fresh, community-led approaches.
Health and care budgets in England need to be merged locally so everyone benefits from investing in prevention. We could learn a lot from other countries. In Denmark, for example, the regions run hospitals but well-resourced municipalities pay a penalty for admissions, embedding prevention and community-based care in the system.
There is no question that the care system is in urgent need of funding reform, but nationalising social care wouldn’t solve its problems.
Rather than rush to an institutional response, let’s start with people – and ask deeper questions about what would make us all live longer, happier, healthier lives. We could then reimagine a system of health and support to enable that ambition.
Jessica Studdert is deputy director of the New Local Government Network
