On 20 March, Secretary of State for Health and Social Care, Jeremy Hunt finally made a speech identifying the principles that will inform the Green Paper on social care that is to be published later in 2018. Melanie Henwood considers what these principles reveal and reflects on their implications. Are there grounds for optimism, or is this just the latest chapter in a series of models for reform that have failed to make it into practice?
There is an unwritten – but golden – rule in political speech-making (as in story telling): pledges should come in neat numbered clusters, often in threes or fives, any fewer and it seems you have nothing to say, too many more and no one will remember them. So, the Health and Social Care Secretary Jeremy Hunt was taking a chance when on 20 March he made his first speech on social care to the British Association of Social Workers, setting out seven key principles to guide the forthcoming social care Green Paper. But the risk is not only that the commitments will prove less than memorable, but that they will fail to be sufficient to address the long-standing challenge of reforming long-term care.
The seven principles cover familiar ground and press the right buttons to connect with important values, but there is nothing here that suggests radical thinking or unexpected developments, or indeed that anything much has moved on since these issues were last on the table. The seven principles are the following:
- Whole-person integrated care.
- Respect and nurture the workforce.
- Supporting families and carers.
- Sustainable funding.
- Security for all.
Another danger with a numbered list is that it implies a hierarchy – rightly or wrongly – and many of those listening to the speech will have been mentally rearranging their preferred order. Be that as it may, the list is largely uncontentious; no one is going to argue against these principles, and they may well be the ‘right’ ones. Some others could have been added, perhaps principles reflecting universalism; building inter-generational solidarity and social inclusion, but this isn’t a bad starting point. The fact that a very similar list could have been proffered at any time in the last decade points to the reality that the problem with social care reform is not with the underpinning principles or objectives, but with how to create an affordable and acceptable funding model that enables these ambitions to be delivered.
It is self-evident that services need to be of good quality and that too often they are not, and that the way services are inspected should play an important part in driving up standards and rooting out poor performance, both in provision and in commissioning. But that improvement agenda will come with a price tag.
Whole-person integrated care
The focus on whole-person integrated care develops a familiar refrain; the fault line running between health and social care creates fragmentation and confusion. It makes it virtually impossible for the lay person to understand or navigate, particularly when they have complex needs and co-morbidities that require a coordinated approach. Joining up services has long formed the core mantra of successive Health Secretaries, and the ambitions for the delivery of the Five Year Forward View for the NHS revolve around the goal of achieving integration through the vehicles of Sustainability and Transformation Partnerships and Integrated Care Systems.
Jeremy Hunt has announced yet more pilots around joint health and care assessment and plans as another step towards integration, adding to the multiple developments around the Better Care Fund and the Vanguards promoting new models of care. But such innovations have not been met with uncritical acclaim; there are flaws in models that chase funding, and analysis by the King’s Fund among others points to the limits of transformation in a ‘downward spiral’ when additional funding is being used primarily to reduce hospital deficits. The National Audit Office has similarly suggested that the ambitions of Sustainability and Transformation Partnerships are overly optimistic.
Announcing new pilot initiatives to address integration by changing systems and processes is insufficient, particularly without addressing the big question of funding, and indeed the impact of separately funded health and care systems on individual users.
Control, the third principle, is about personalisation and people having scope to direct their own care and support, and access to the information and support they need to do so. Again, these are familiar words that have been part of the lexicon of care for more than a decade, and still the reality for people is often very different. How we get to the destination remains unclear; merely repeating the familiar and warm words is not enough.
Respect and nurture the workforce
Respecting and nurturing the social care workforce is overdue; these are the underpaid and undervalued care workers who are too often the focus not of praise but of criticism. The announcement that there will be a joint NHS and Social Care 10 Year Workforce Strategy is welcome, and an opportunity to address critical issues of recruitment and retention, career pathways and promotion opportunities that will attract and support people into working in social care as a valued career choice.
But the strategy will need to address the reality that many people in social care are not going to want to move into nursing, or to follow a career path. The need to embrace the skills requirements and opportunities for people who will continue to provide vital day-to-day personal care for people in their own homes and in the residential sector must be part of the strategy, as must be the question of regulation and accountability for groups that are still outside the framework of professional regulation.
Supporting families and carers
Support for families and carers made a welcome appearance as a principle identified by the Health and Social Care Secretary. Indeed, many will have wondered what had become of the National Carers Strategy that was consulted on almost two years ago, and then disappeared from view. Hunt confirmed that “ahead of the Green Paper we will publish an action plan” on how to support carers. What that might look like is not known but Jeremy Hunt confusingly spoke in the same breath about volunteers, and about tackling loneliness, which might suggest that clarity around an action plan for carers is still a little way off.
Sustainable funding and security for all
The last two principles – sustainable funding and security for all – finally get to the big issues that remain unresolved, but fail to indicate anything about how they might be addressed. The Green Paper is still primarily about funding long-term care for older people, and the decision to separate this from a wider consideration of care needs for younger disabled people was widely criticised when it was announced following the 2017 election. Some sign that this approach may be shifting was evident in Hunt’s acknowledgement that the answer will not “be necessarily the same for different age cohorts” and that “there may be changes that are equitable and achievable for younger people that would not be either of those for the generation approaching retirement.” Getting a sense of inter-generational solidarity and buy-in to a revised social contract will be critical to reform, and any approach that salami-slices the population risks instead becoming highly divisive.
Hunt underlined the principle of “shared responsibility” in achieving security for all, with a “partnership between the state and individuals.” But importantly, he accepted that the current system “is far from fair”, particularly in the lottery of health which means fully funded care for illnesses such as cancer, and largely unfunded support for people who develop dementia and degenerative conditions. The Green Paper will present ideas about risk-pooling and potential costs, and will need to do so in a way that avoids earlier criticisms of a death tax.
Breaking the silence on long-term care is an important step, but the debate has barely moved since it was last visited. The Care Act remains on the statute books, but the implementation of the capped cost model of funding has been cancelled, and we are back to a position many would think we were in following the Dilnot Commission’s report in 2011. The confusion which surrounded social care during the 2017 General Election campaign caused a rapid unravelling of the policy; whether the seven principles for the Green Paper will provide a sufficient foundation for development and for genuine fresh thinking remains to be seen. On the basis of what Jeremy Hunt has outlined so far there is perhaps some reassurance and hope that a principled way forward will be found, but certainly there are no grounds here for excitement or unbounded optimism.
Melanie Henwood, independent health and social care research consultant.