Heading in to the 2024 general election, there is every indication that adult social care might be overlooked again. Over time, various governments have pledged to fundamentally reform the system – a recent iteration of this was Boris Johnson’s ill-fated pledge in his first speech as Prime Minister, standing on the steps of Downing Street, to ‘fix the crisis in social care once and for all with a clear plan we have prepared’. Governments get part way through reform planning, realise it’s too difficult politically, and delay or abandon reforms. This tendency for ‘drift’ seems particularly pronounced in England – Needham and Hall’s (2023) ‘Care in the Four Nations’ research found that other parts of the UK were making more progress on care reform.
Even when debate does seem genuine, it only really focuses on the bits that touch the NHS (often around older people’s services and delayed hospital discharges) and the issue of who pays for care homes (an important topic, but essentially an issue about inheritance rather than about the nature of the care provided). As the House of Lords Adult Social Care Committee has argued, adult social care is too often “invisible” – taking place largely behind closed doors in people’s own homes; not valued by broader society; poorly understood by policy makers, the media and the public; and often seen in negative terms as a ‘burden’ on scarce resources.
If this is to change, then we need to address the ‘why’, ‘what’ and ‘how’ of adult social care reform.
First the ‘why’. Too many previous campaigns to reform and properly fund adult social care have failed, in part because the nature of the ask is often negative. As Glasby et al (2021) have argued in their work on behalf of Downing Street, updated with funding from the ERSC, spending on social care is too often seen as ‘dead money’ that governments have to spend in order to satisfy basic public expectations – it’s about providing a basic safety net, spending as little as you can get away with. Instead, we need to see social care as a form of social and economic investment we make in ourselves as a society – helping us all to live chosen, meaningful lives and to flourish in our relationships, friendships, and local communities. This has been brilliantly captured by the social movement #SocialCareFuture, who have developed a really positive, inspiring narrative to help reframe these debates:
“We all want to live in a place we call home with the people and things that we love, in communities where we look out for one another, doing things that matter to us. That’s the social care future we seek.”
It’s also captured in the title of the recent House of Lords report – who wouldn’t want a “gloriously ordinary life?”
Second, the ‘what’. We already have a series of approaches which promote choice and control, which connect people to each other and to local community resources, and which help people with care and support needs, and their families, to lead the kind of lives they want to lead. Really good examples come from the work of the Social Care Institute for Excellence on assets-based places, and with linked models such as Local Area Co-ordination, Shared Lives Plus, micro-enterprise and many more. Above all, we have direct payments – invented by disabled people themselves to gain greater control over their own lives, and still one of the most powerful ways of ensuring that decisions that really matter to people get made as close as possible to the person they affect – ideally the person themselves. Unfortunately, all the previous evidence (e.g. Glasby et al, 2018; Needham et al, 2022) suggests that it can be all too easy for previous ways of working to re-surface, for old approaches to co-opt the new language and carry on as before, and for power imbalances to remain unchallenged.
This brings us on to our third point: the ‘how’. IMPACT is the UK centre for implementing evidence in adult social care, funded with a £15m investment by the ESRC and the Health Foundation, to get evidence of what works used in practice to make a difference to services and to people’s lives. People tell us that they have ‘policy’ (which tells them what to do) and ‘evidence’ (which indicates things that might be fruitful) – but that the difficult bit is actually doing it in practice, in the realities of very pressured, local services. As a result, IMPACT’s various delivery models focus on practical support on the ground, helping people to draw down insights from the evidence, implement changes and understand what impact this has had. It’s a form of ‘learning by doing’, and it’s exactly the kind of practical support that has always been scarce in social care, but which was particularly hard-hit by austerity. Services rightly focused on front-line delivery, but at the expense of the capacity, support and skills needed to implement change.
If history is anything to go by, therefore, the 2024 manifesto season might see a series of promises about adult social care – with little actual reform on the other side of an election. To break out of this cycle, we need a proper vision for what we’re trying to achieve (the #SocialCareFuture narrative is perfect for this); to do the things we know work/stop doing the things that we know get in the way; and to properly support people trying to do things differently. A summary of the House of Lords report was clear that this is crucial for all of us, and that we can’t wait any longer:
“Adult social care affects the lives of over 10 million people in England, including those who draw on care and support, unpaid carers and paid care workers. Over the coming years it will affect all of us, one way or another. It’s everyone’s business… [Fundamental] changes are necessary for us all to live ordinary, meaningful lives, and to create the kinds of communities where we all look out for one another.”
About the authors
Jon Glasby is Professor of Health and Social Care at the University of Birmingham and Director of IMPACT, the UK centre for implementing evidence in adult social care.
Catherine Needham is Professor of Public Policy and Public Management at the University of Birmingham and part of the leadership team of the ESRC Centre for Care.
Photo credit: Dominik Lange, Unsplash