In answer to the question ‘how do we close the gaps in adult social care’ I am going to focus on three areas: changing the terms of this debate to reflect better the benefits of investment and reform of adult care services; the sort of reform package I believe we need; and of course the big question – how to finance it.
In many ways this issue has dominated current discussions and lost what I and others believe is the core issue: what kind of services and level of support we deem acceptable in 21st century Britain.
What is social care for and about? If I may I will first draw on personal experience. My social care needs are categorised as fitting in the critical and substantial banding, but that simply means that I receive help getting in and out of bed, preparing meals, and going to the toilet. I am fortunate in that I have a job that enables me to supplement state provision in ways that hundreds of thousands of other disabled people cannot.
So when we hear, as we did last week, about local authorities ‘tightening eligibility criteria’ and people ‘lost to the system’, this is what it means: not having a shower each day, waiting to go to the toilet, not being able to leave the house because you cannot get a coat on. And it certainly means very limited support to lead a normal social life, like others enjoy, and it definitely doesn’t mean support to participate in political life!
When we debate the future of adult social care, this is what we are discussing.
And losing people from the system does not impact on individuals alone, but also on those with whom they share their lives. Millions more people will be caught between the growing demand for care in an ageing society and retreating public services. Many more will, involuntarily, join the six million UK people labelled ‘carers’, praised for their compassion and then overlooked.
The overwhelming number of carers are aged 40-65 and a significant majority are women. Many have to give up work, claim benefits and need a state pension, often living in poverty. Many also experience poor health and become increasingly reliant on health services. Is this sustainable? When discussing social care, we are also talking about gender equality.
When local authorities restrict eligibility criteria, it also means increased demand on young carers. The 2001 census shows 5,500 children as young as five providing substantial levels of support. Almost 70 per cent of workless households with children include at least one disabled parent, and one in three children in poverty has a disabled parent. It seems hard to understand how, without adequately addressing adult social care needs, the government will reach its targets on child poverty. So when we debate the future of social care, we are also debating child poverty.
We heard from Dame Denise Platt’s CSCI State of Social Care report that access to services – through eligibility criteria – is being restricted. Seventy three per cent of English local authorities are only responding to critical and substantial needs. In 2006, 121,000 fewer households receive homecare compared to 1997 (358,000 to 479,000). In 2006, 13,000 fewer older people receive support in in 2003 despite a 3 per cent rise in people aged 75 years or older.
By cutting access to services, many local authorities are failing in their duties to promote human rights to private and family life. Some, it could be argued, are failing to prevent inhumane or degrading treatment. When we debate the future of social care, we are also debating human rights.
So when we debate social care, what should we be discussing? First, it’s about people receiving the support they need in order to be equal citizens with equal life chances, able to participate fully and exercise their responsibilities. Second, it’s about our relationships with one another; third, it’s about poverty, health and wellbeing; fourth, it’s about our human rights; and fifth, it’s about the effective and efficient use of public resources.
To get the debate going on the kind of reform I believe we need I propose three ideas today – much of which there is government action on.
First, rolling out individualised budgets and maximising initiatives and models that can afford greater choice, control and efficiency. But ensure that this is done properly, and including all relevant funding streams including access to work and health funding were relevant.
Second, meeting the commitment of the 2005 Strategy Unit report on the life chances of disabled people for a user-led service in every local authority by 2010. But also looking at how existing services can individually or collectively provide the framework of advice, information and advocacy people need to exercise choice effectively.
Third, make the Department for Communities and Local Government an equal partner in this debate, especially in relation to the ‘low level’ services which enable people to stay independent, safe and healthy in their communities, giving specific attention to those factors which influence demand for social care services such as accidents in the home, social isolation, or harassment. Challenge that Department to look at these issues in the context of community cohesion.
And last but not least – funding. What can we afford and how do we pay for it dominates this debate. The government routinely refer to the pending reform as the ‘funding green paper’. This worries people – older and disabled people and carers alike. It sounds like more restrictions. There seems to have been a significant voice missing from discussions so far; there are still countless citizens and organisations who support free universal care for all at the point of need and irrespective of means.
Northern Ireland is about to introduce free personal care allowing further discontent to fester with the crisis in care services in England. For many disabled working adults social care services are a mechanism to provide them with equal life chances and participate fully as equal citizens. Let us not forget that charging these individuals for social care services is effectively an additional tax on participating in society.
We also need to draw adult care reform discussion together as, confusingly, there are three debates running concurrently: how to finance the needs of older people; how to support carers; and how to promote independent living for disabled people. If we believe in independent living for disabled people, then that should be a central goal of any discussion around funding care, or about support for carers. Any debate about independent living for disabled people needs to account for family members and finances. We need one debate: how to promote independence, choice and wellbeing for people requiring support and their families. Surely we should be deciding what we want our social care services to deliver before we start debating how to pay for them.
But I want to come back to the different questions I have posed: what will be the opportunity cost of not making sufficient investment in social care? How, through investment and reform, can social care contribute to economic growth and prosperity in an ageing society?
First, we all accept we can use existing resources more efficiently, reducing bureaucracy and putting control into the hands of users. Social care efficiency savings must be hypothecated however – and not also lost to the system! Ring-fenced resources would be a step forward.
Second, by giving people greater and more flexible support, many more people will be able to work. I believe a priority for care reform should be to increase the numbers of disabled people and carers who work. In this sense social care, like childcare, will become the new frontier of an active welfare state. This would of course help tackle the numbers of disabled people on incapacity benefit, and pensioner and child poverty.
And we need to get serious about prevention, adopting a public health model and embedding clear targets across our public services to reduce the chance of people avoidably developing high level needs.
But we must face up to the fact that if we really want prevention, information and quality, it is going to cost us. Fine words are being spoken, but only through a significant reprioritisation of social care will we meet the real challenge of the coming years. A serious debate about the future of social care must present the real choices we face and their implications.