Care… the work that makes all other work possible

Most of us will need care at some point in our ever-longer lives. Richard Humphries argues that it’s time we recognised its importance and legislated and funded it properly

Economist and former national statistics chief Andrew Dilnot tells a story about the myth of a golden age when grandma was looked after in the bosom of her family, sitting by the inglenook fireplace knitting socks for her grandchildren. It was a myth, he explains, because grandma didn’t exist – grandma was dead.

It’s a story that encapsulates the sweeping changes engulfing society since the end of World War II and why social care is now one of the pressing public policy challenges of our generation. Back in the 1940s not that many people lived long enough to need care and those that did were poor enough to get it free. Mostly, this was institutional care in former workhouse buildings and long-stay hospital wards.

Few people had homes to sell. Instead, universal health care was the big priority. Alongside the popular acclaim for the newly created NHS – the poster-boy of the welfare state – the opening words of the parallel legislation for ‘welfare’ services, the National Assistance Act, said it all, describing it as ‘an Act to eliminate the Poor Law’.

Seventy-four years later, our population is much bigger, we are living longer and many of us experience chronic long-term health problems that – thanks to the success of modern medicine – we will live with, not die from. As a result, most of us will need some degree of care and support at some point in our lives, usually, but not always in our later years (needs are in fact growing fastest amongst the under-65s). We are generally much better off and many of us enjoy the wealth that puts financial help from the state out of reach – because, unlike health care, social care is not free at the point of use.

Unlike other big policy challenges such as climate change, sustainable energy, crime, poverty and inequality, the crisis of social care is born of success, not failure. Yet successive governments have failed to address the consequences of the rapid march of social and economic progress. Today England is paying a heavy price for decades of policy neglect. More than 500,000 people are now waiting for social care. Whereas NHS treatment and spending have expanded over the years, reflecting increasing needs and a bigger population, the trends in social care have been demography-defying. Fewer people are getting support than a decade ago and real terms spending has fallen, despite recent short-term cash injections. Staff vacancy rates recently reached a record high of 165,000.

By a process of administrative accident, over 90 per cent of care is delivered through private bodies, creating new concerns about accountability and quality. Crucially the social care system seems to have forgotten its primary purpose of helping people to live better lives, with people using the language of military conflict to describe their experience of seeking support and the reduction of care to basic ‘life and limb’ functions at the expense of quality of life. 

In a climate of deepening political psychodrama and economic turmoil, the prospects for social care reform are inauspicious, amidst a plethora of competing policy priorities and the overriding need to restore fiscal confidence. With reports that the government’s flagship policy of a cap on individual care costs (a limited measure in any case) is set to be postponed, it is clear that more of the same will not work. Instead, a different road to reform is needed to secure political traction and public support for change. This would involve replacing traditional, top-down policy-making with a different process using co-production, deliberative democracy, consensus building and drawing on new thinking about long-term policy-making.

The goal of reformers should not be to lobby politicians to support unpopular or unfamiliar policies but to convince voters that investing in good social care, like universal health care, has great benefits for people and society. The predominant mindset that views care as a cost, a financial burden or a politically toxic problem that is just too difficult should be replaced by a recognition that all advanced countries depend on good social care as part of their economic and social infrastructure, in the same way that they depend on investments in education, skills and health care. As American campaigner Ai-jen Poo describes it, it is the work that makes all other work possible. On this positive foundation can be assembled three new building blocks for better care:

1. A new social ‘contract for care’ that sets out the mutual roles and responsibilities of individuals, families, communities and central and local government.

2. A different model of design and delivery that gives people new rights and resources based on entitlement not professional discretion, including a new deal for people who provide care and support, both paid and unpaid; there is a wealth of locally generated ideas and innovations that can be drawn upon to give people new choices and options about their care and support.

3. A new funding settlement that positions social care as a major public service in its own right, on a par with other universal services such as education and health care.

We should not allow the dreadful economic and fiscal climate to extinguish hope that fundamental change is possible, as the post-war Welfare State testifies. If anything, recent events strengthen the case for social care investment as an integral feature of economic and social reconstruction and recovery.

Richard Humphries is an RSA Fellow, independent social care expert and author of Ending the Social Care Crisis – A New Road to Reform published by Policy Press on 27 October 2022. A version of this piece has also been published on TransformingSociety.