We welcome this week’s publication of the Local Government Association’s Green Paper on Adult Social Care and wellbeing The Lives We Want to Lead. Someone had to do it. The Government’s promised green paper appears to have been kicked beyond the long grass and into dense thicket, and it’s beyond time local government took the lead on solving this crisis. Waiting for central government to provide solutions to a crisis which has been long ago foretold has simply led to a stagnation in the delivery of care and deepening financial chasm between what we can deliver and what we ought to be able to.
There’s little to disagree with in the green paper. Yes, the social care funding crisis is leaving too many people with unmet and under-met care needs. Yes, the local authorities’ moral and legal imperative to serve those who need care is eating away at the other things that local government needs to provide to its communities.
We certainly welcome the LGA’s emphasis on wellbeing. Councils manage not just services but places. Places where people live those lives they want to lead (or not). It is important to recognise not just the democratic accountability that councils have and the trust that citizens place in them to make decisions about what happens locally, but to emphasise the broader contribution that living in a thriving and resilient community makes to any given individual’s quality of life.
However, there were some things missing from the green paper. While there is certainly mention of reform and of the plight of self-funders, there is little there to really address the concerns of how most of us will pay for social care if and when we need it. There is a costed option for delivering personal care (c. £6 billion) to all who need it, but by delivering it in much the same way we do now – commissioning for time and task in practice and occasionally for outcomes in principle. (LGiU members can read our latest briefing, published today, on long-term sustainable funding for adult social care which includes a summary of the LGA green paper and other reports focusing on funding adult social care)
To really solve the social care funding crisis, we need to find ways to help individuals pay for their own care, whether that is through individual financial products or through a state insurance system or a combination of the two – which could support older people and those working-age adults who need support. Either way, we need to ensure that individuals have a financial incentive to stay as healthy as they can by allowing assets to pass into an estate if they remain un-depleted, while never leaving people without the personal care that they need if they need it even if they use up all their contributions.
Even if the state doesn’t step in to support self-funders to create ways to pay for their own care, Government must create enough policy certainty to allow the financial industry to cater to the better off and the prudential risk-averse who would like to purchase insurance. Now and for the past decade or so, there has been no clarity about whether or not there might be policy reform and what shape it might take. The possibility of cap and floor or the (slim) possibility of Scottish model of free personal care alongside a lack of transparency in costs and access to state funded care makes it nearly impossible to create an insurance market. That has to change.
To really reform adult social care, we must at last get into the thorny discussion of what to do about the NHS and public health. There are those who argue that we should merge the health and social care systems. And it can certainly be said that attempts at integration have not been universally successful and it is truth universally acknowledged that we are in want of a system where health and social care are working toward the same goals and with a high level of institutional trust.
Alas, the NHS will always (and perhaps rightly so) focus priorities on the acute and the emergent – prevention, rehabilitation and ‘low’ level chronic conditions which can impact the quality of daily life always seem to take a back seat to the often excellent care delivered to the critically injured and the desperately ill. While there seems to be genuine agreement that part of the the NHS budget crisis stems from underfunded community health and care services, it seems unlikely that any government would ever make the choice to strip the NHS of funding to give to cash-strapped social care even if over-all we think it would be cost-effective. No politician wants to face an angry constituent who believes that life-saving, cutting-edge cancer care for their child has been denied in order to make an older person’s final years more dignified, independent and comfortable.
We should have the conversation that needs to be had. Let us dispense with the notion that the NHS is a health service – and let it do what it does best – deal with the difficult and dangerous. Let local government does it what does best, curate interdisciplinary services which make communities thrive and support individuals to lead better, healthier lives in safe homes and prosperous communities. With a single, democratically accountable body in charge of care, community and public health, primary health care and the determinants of a healthy life (green space, movement, nutrition, housing, and social connections) we have a real chance of delivering better outcomes for individuals.
Finally, we need a better focus on outcomes. We can no longer commission care based on time and task. It leaves both the caring and the cared for feeling like cogs and commodities in an uncaring system. We need a real outcomes based commissioning based on real time information about people’s actual needs and experiences. In September, we will produce a paper setting out how this can be done.