They illustrate that there are some fundamental points of disagreement that can’t be reconciled. You cannot, for example, satisfy both the person who wants to fully nationalise social care and the small private provider. Here politicians and policymakers will have to make a clear choice.
Yet in most cases, there is the opportunity to strike a balance and accommodate different perspectives. Social care policy reform should not be a zero-sum game. It is possible to design a system that both supports people using services and reduces demand on the NHS; provides more support to people who need ‘a little bit of help’ and financially protects the homeowner who needs to go into a care home; invests in both the workforce and technology; and recognises and supports the role of the family carer but also offers effective support from the state to them.
A starting point is to better acknowledge and understand those different perspectives on reform. So, which of them are you?
1. The homeowner: ‘I shouldn’t have to sell my house to pay for care’
‘I’ve worked all my life to pay off a mortgage and to save money for my old age. But if I get dementia and need to go into a care home, all that money will go to pay my care home fees. There’s no way I can protect myself from it and that's not fair. I’d always thought I’d be able to leave something for my family but now that’s not going to happen. If I’d not saved, I would get free care from the state so I’m being punished for being responsible.’
2. The NHS defender: ‘what matters is the impact of social care on the NHS’
‘Social care is a key part of a health and care system centred on the NHS, and acute hospitals in particular. That’s where most of the money goes, after all, and it’s what people most prize. Social care needs to reduce demand for NHS services by preventing problems from emerging in the first place and by making sure we can get people out of hospital beds as quickly as possible.’
3. The radical transformer: ‘only fundamental reform of care will do’
‘Formal social care services are only a small part of the much wider support networks that exists in communities. People have far greater strengths than we think, and we often provide the wrong sort of support because a bureaucratic system becomes a machine for distributing and policing care packages. We need very different types of support but they won't come from the current structure: it requires a far more fundamental change in the power dynamics within local areas.'
4. The family-firster: ‘care is the responsibility of the family, not the state’
‘Families should take the primary individual and collective responsibility for looking after elderly relatives or younger members with disabilities. I certainly don’t want to put my mum in a care home; if she needs help she’ll come and live with me. Yes, the state should take some financial responsibility for people who have no family to help them, or have really intense needs that can’t be met by families, but it should be the support of last resort, not the first’.
5. The nationaliser: ‘if Bevan was creating the NHS now he’d have included social care within it ’
‘It’s immoral to have private companies making a profit out of providing care to people. Many of them are making enormous profits by exploiting their workforce and charging huge fees for services. So all provision of social care should be carried out by public service employees and be free at the point of use, just like the NHS. There’s no meaningful distinction between health and social care anyway. Social care should be a public service, provided in the same way as the NHS.’
6. The economic forecaster: ‘there’s going to be a huge increase in demand for care and we need to work out how to pay for it’
There are more older people living longer and more working age adults living with disabilities. First and foremost, we need to find a way to pay for them. This also requires us to be more efficient in delivering care and improving its productivity. It’s not clear why the state should take on a care and support role that is already being carried out by families. Any reform has to be affordable and how it will be funded needs to be set out.’
7. The personaliser: ‘I just want care that’s centred on my needs, not determined by the services that are available’
‘I’ve got complex health and care needs. I have a direct payment to manage my care but it’s not enough to cover basic things like going out and socialising. It’s also heavily policed by my local authority – I’m not allowed to spend it on things that I know would really help. It really shouldn’t be this difficult to get decent care that’s centred on what I want and need as an individual, but in practice I often experience disjointed care from different parts of the system. There’s also a problem finding a decent choice of services.’
8. The beleaguered provider: ‘I just want a decent rate for my services’
'I operate one small care home which has been in my family for 20 years. We do everything we can to provide our residents with the very best, most personalised care we can. We get great feedback from families. We don’t make huge profits – just enough to reflect the amount of time and energy we put in – and to invest in our property. We try to pay our staff a decent amount but it’s hard. We just need a decent rate from our local authority commissioners but we don’t get it and I wonder if we can survive.’
9. The overwhelmed carer: ‘I’m at my wit’s end trying to care for my dad and husband’
‘I look after my dad, who has dementia, and my husband, who has a long-term health condition. I want to do it but I just can’t cope. I’m always being told that carers are critical to our health service and we do a marvelous job. That may be true, but it doesn’t help me pay the bills – I’ve had to give up work to do this. My own health is poor and I often miss appointments because of my caring responsibilities. I need more respite, more recognition and more support.’
10. The workforce campaigner: ‘it’s all about paying careworkers more’
‘Careworkers are underpaid: they could earn more as a cleaner or shopworker. Their pay in no way reflects the nature of the role, which has become more complex over time. It’s a matter of simple social justice that we pay careworkers a fair rate for the job and give them the training they need and career opportunities they deserve. This should be the priority for reform.’
11. The needs-thresholder: ‘I just need that little bit of help to stay in my own home’
‘I’ve had an assessment by my council but it turns out my needs aren’t high enough to get support. Apparently there are hundreds of thousands of people like me. I don’t need help with washing and dressing but I would love to have someone to help clean the house, do some shopping for me and change that lightbulb. I also could do with the company.'
12. The local authority commissioner: ‘I just need more money’
‘Since 2010/11, we’ve seen a fall in the amount of money we have to on adult social care but requests for support keep on going up. I’m as worried about the demand from working age adults, particularly those with learning disabilities, as I am about that from older people. We’ve held down rates to providers as far as possible and in truth we’ve also rationed care. I want to invest more in areas like prevention but I don’t have enough money to do anything more than meet the most urgent need. Wider reform will have to wait until I’ve got more to spend.’
There are more viewpoints, of course. There is no place here for the innovative provider (‘my services work but I can’t get them widely commissioned’), the hi-tech disrupter (‘robots and technology will transform social care’), the ageing-denier (‘I will never need care so I don’t intend to plan for it’), the systems-thinker (‘it’s clear that when you cut social care, the NHS bleeds’ ). You may well be aware of others.
We are all, in all probability, some combination of these personas. Reform will require us all to compromise and prioritise. Recognising the starting positions is the first stage to doing that.