England’s social care sector has every right to feel neglected. However perverse the logic of doing so the NHS always pushes to the front of the queue for cash from the Treasury. This is true despite the repeated failures of the NHS to deliver promised reform and despite its demands for front-loading of new money just leading to new demands when the front-loading ends. Even the head of NHS England said that any new money should go first to social care. Seventy years after the creation of the modern welfare state it remains a sickness service; treating consequences and neglecting causes.
Whereas the review led by Derek Wanless for the Treasury asked how different the picture might be if public services and the population fully engaged in prevention, this ambition has been all but abandoned in favour of sustaining our sickness service.
What now for social care? The scale of the latest NHS indulgence by the Treasury, imposing further austerity on other public services, has removed the scope for substantive new tax-funded investment in social care. Instead the focus will have to shift back to managing the transition to a system within which individual households make better provision for these costs, and to find solutions to staying out of costly residential care to the maximum extent possible. The current model, in which cash-strapped local authorities are the reluctant broker in a market focused on cost-minimisation above all else is both unsustainable and unacceptable.
The growth of equity, particularly in homes and pensions, offers part of the solution. Far from a dramatic extension of state involvement, the innovation and improvement in quality and personalisation that is needed can only come from greater popular involvement.
Long-term care of the elderly has always been an insurable risk, but the framing of the topic in Britain has simply crowded out the demand side. The “cradle-to-grave” rhetoric is a much a lie today as it was in 1948. Elderly care was side-lined by Bevan and remains side-lined today. Only when politicians are honest about this fact will there be an incentive to find new ways to provide for elderly care.
Whilst the state might sensibly be the insurer of last resort, as in the various proposals for a cap on lifetime care costs, the policy rhetoric needs to shift if it is to foster demand for new solutions. Since the creation of the NHS the British people have adapted their expectations in dentistry, optical services, and medicines; directly spending billions of their own money on products and services in innovative and competitive markets that would have been unimaginable under the NHS. Some 35 years after the arrival of a mixed market of supply in elderly care a similar shift of expectations will be the first step towards a sustainable solution. But it requires bold and honest policymakers.