Social care lies low on the political funding priority and public sympathy radar, with social care funding having acquired the totemic status of a black hole, says Andy Cowper

Auto-erotic asphyxia being as it is a niche pursuit, I hope no readers have been holding their breath for the government’s green paper on social care, which Secretary Of State For The Time Being Matt ’Ancock had promised would be with us by April.

There was, as I noted at the time, no specification of which year’s April.

This column has passed a few bits of verbal jousting into the health policy lexicon, but perhaps the fairest one was my renaming of The Artist Formerly Known As The Department Of Health as the Department For Health But Social Care.

As I wrote in January 2018, “social care is broken, because of deliberate decisions by the coalition government and the current government to remove vast amounts of the Revenue Support Grant. The government’s permission for local authorities to levy a small precept on council tax does not come close to thinking about touching the sides of this funding hole.

“Social care providers are exiting the market as if there were no tomorrow (which means that for quite a lot of people who need social care, there won’t be).”

Electioneering black holes and black spots

There is a morbid symmetry to note that in this week of the publication of the first images of a black hole, in electoral terms, social care funding has acquired the totemic status of a black hole and a black spot.

In 2010, the Tories attacked Mascara Kid Andy Burnham’s ideas for funding a universal national care service through changes to inheritance tax as ‘Labour’s Death Tax’. You have to wonder whether slightly more thoughtful Tories, of whom some exist, are rueing Andrew Lansley’s policy choice yet.

Labour returned the favour in the 2017 snap general election, with the Tories’ proposal slightly rebranded as a “dementia tax”, forcing Theresa May into her now-infamous “nothing has changed” U-turn.

The four-year itch

Serious brains have looked into social care funding:  Derek Wanless’ 2006 review, Andrew Dilnot’s 2010 review, Kate Barker’s 2014 review and Anita Charlesworth and colleagues’ 2018 review.

The clear pattern of a four-year itch for a major review of social care funding options is unmistakably a chronic illness of the system. And nothing is worse than having an itch you can never scratch.

Recent health questions in the NatCen British Social Attitudes survey found that 34 per cent of the public surveyed believed that adult social care is provided for free by the NHS. (A cynic might suggest that the other 66 per cent just haven’t thought about it yet, or had recent experience of trying to get social care for a friend or family member. Thank goodness I am not a cynic.)

The major social care funding reviews cited basically all suggest that if it is to remain funded by individual contributions, that a lifetime cap at some level is probably reasonable. Dilnot suggested £72,000, which the coalition government accepted in principle in the early days of austerity, but delayed in practice.

Is any progress likely? It’s hard to see it happening, at a time when other areas of the public sector, from schools to local government to prisons are all in need of significant resource increases. But the principles that should underpin what a fair system would look like were neatly outlined in this fine piece by Camille Oung and Laura Schlepper for the Nuffield Trust.

Long standing fans of health policy may recall the debates of the 1980s and 1990s (and probably the decades before that) about when a bath for an older person with support needs would count as a health bath and when it would be a social care bath.

Social care faces a range of problems to get up the public policy and indeed general public agenda – its name is unhelpful at describing clearly what it is; it is un-aspirational, being generally associated with dependency, older age and infirmity; and its non-universal, means-tested nature has unfortunate connotations of benevolence, charity and paternalism.

The universal welfare state model made free healthcare, like free education, feel like a right. Time and Treasury Munchkins have nibbled away at it, but as Nick Timmins’ magisterial The Five Giants concludes, the principles remain broadly intact.

Social care has never felt like a right, I suspect. As such, its best chance of winning the political funding priority/public sympathy argument will be a stronger alignment and alliance with the halo-suffused NHS brand. Preferably with the bits of it that people understand and which are open 24/7. Hello, the acute sector!

There could also be some lessons from the history of the Institute of Medical Social Workers, which arose from two distinct organisations for hospital almoners. History is not destiny (thank goodness), but it often teaches us valuable lessons, if we keep our ears and eyes open.