Social care reform: fit for purpose or simply fit for a crisis?

The Covid-19 (coronavirus) crisis has laid out in stark relief just how critical social care is to the people who rely on it to live the lives they want to, to communities and the economy, and yes, to the NHS too.

Too often, politicians of all parties decided they couldn’t afford the political capital and the financial cost of social care reform. We can only hope that the current crisis is showing that they can’t afford not to.

There is a risk that when the case for change finally lands with politicians and the public in the midst of a crisis, the lens by which solutions are assessed is also through a health care crisis. We could end up creating a new social care system fit for a crisis but not fit for its purpose. The idea of moving social care into the NHS, an idea almost as old as time itself that is again circulating as a solution, may well encapsulate that dilemma.

There is a risk that when the case for change finally lands with politicians and the public in the midst of a crisis, the lens by which solutions are assessed is also through a health care crisis. We could end up creating a new social care system fit for a crisis but not fit for its purpose.

It’s not clear what is meant when people say ‘let’s bring social care into the NHS’. For some, it means introducing into social care the same principle of care being free at the point of use (although there are user chargers in the NHS). For others it means moving social care into the NHS, being commissioned and delivered by the NHS, or it’s a hybrid, where social care is free, commissioned by local government and delivered by the NHS. Across these options, there is confusion about what is determined nationally, between delivery, funding and entitlement. The fact that there isn’t agreement on what moving social care into the NHS means might suggest it is not the panacea some hold it to be.

There would be benefits to bringing social care more firmly into the NHS. Benefits that come at considerable cost, and each could be delivered with other types of reform too.

The strongly felt sense of unfairness that our health needs are paid in full, but for our social care needs we get little or no support would be eradicated. We would all have the peace of mind that whatever our condition – be it cancer, dementia or MS – we would have all of our heath and care needs covered.

Our social care workforce would also benefit from better terms and conditions if delivery was part of the NHS provider structure. Care workers, who do critical work every day, are now being recognised as key workers by the community. They deserve better pay, better reward and better recognition, all of which would come with the NHS brand and the Agenda for Pay pay structure.

But, if we wanted to, we could give people a universal entitlement to social care without bringing it into the NHS, and likewise create better pay and career structures without moving it to the NHS.

'But, if we wanted to, we could give people a universal entitlement to social care without bringing it into the NHS, and likewise create better pay and career structures without moving it to the NHS.'

The argument goes that we would also see more integration between health and social care if social care was part of the NHS. There is potential here, although it’s worth noting that the join-up between different NHS services is by no means perfect, so there is no guarantee that being within the NHS tent would make services more joined up by default. Just look at the historically poor link between physical and mental health, or that more delayed transfers of care arise from health needs than social care needs and you will see better integration is not guaranteed.

There is also an emerging narrative that it would just be ‘easier to get things done’ in social care if it was more like the NHS – more able to respond to a single command and control structure, with it being possible to pull levers nationally and see consistent change locally. But even in normal times, ‘national’ health services do not mean there is no variation in access or quality of services. Whether more national control would make it more resilient in the face of future crises is open to debate – we can just look to local government’s ability to respond from within communities locally across a huge range of Covid-19 issues to see there are other ways to effectively respond to crisis.

But moving social care into the NHS brings with it major concerns. These concerns have long been held by people who rely on care and support and by people who pride themselves on delivering person-centred care in the sector. These voices must be at the heart of the debate, and heard loud and clear as reform options are considered.

There is a real risk that shifting social care to the NHS will see the model of care move to a medicalised model. Much of the NHS defaults to this type of approach, and it is very good at it. But it isn’t the type of care and support people want. Social care should be about helping people live the lives they want to live. It’s not about medical interventions; it’s about a type of care and support and a type of philosophy that the NHS does not have a good history of.

Social care should be about helping people live the lives they want to live. It’s not about medical interventions; it’s about a type of care and support and a type of philosophy that the NHS does not have a good history of.

There is also a risk that there would be a shift away from services that – when social care is at its best – are person-centred, based on skills and assets within the community that allow for many different services to develop to meet people’s diverse needs and aspirations. While there have been some encouraging early signs that primary care networks (PCNs) could be strong allies in this way of thinking, we are long way off this being the default in how the NHS thinks and behaves. Until it is, we risk a detachment from local community strengths, which would mean the quality of life of those needing care and support would be poorer. Whatever the intention of numerous policy initiatives over the years, the NHS has a long-held tendency to favour building-based services at expense of community services and development.

When we think about social care reform, too often the framing of the problem has been how to pay for care. Now, the frame may shift to how can the sector be more resilient to future crises and how it can be a better support structure to the NHS. But this would miss the point. When we turn our collective minds to social care reform once more, our thinking should have at its heart two questions. How can we help those that need care and support – now and in the future – live the lives they want to lead? And how can staff working in the sector have the recognition and reward they deserve for supporting those who need care and support to live the lives they want to? In plotting a path to long term reform, we will need to make trade-offs and compromises along the way, but if we hold those two questions close, we stand a chance of creating a new system that is fit for purpose.