For a decade we have debated the future funding of social care. The debate has mainly focused on the key question – who should pay for care costs – the state or the individual? In this short piece I want to pose two issues in this debate – first, is this the right question and, second, why should we not retain the current means-tested system for social care?

For the past 50 years there has been little political debate about the nature and the role of social care in British society. Major political differences between the parties have tended to focus on who should pay for the care and how care might be arranged. The key question from which politicians have steered away is what kind of care service do we want? Traditional Labour, radical nationalists, liberals and deep conservatives have all held what might be called the paternalistic model of care. ‘The state will help you to get the care to which you are entitled when you have needs. You will be eligible if your needs are high and you have no means to pay for the cost yourself’. The debate has rarely focused on why some people have needs and others do not (with similar conditions) and whether we have got the right set of interventions to help meet needs.

For older people the two most common factors which bring them to need care  are poor health and social isolation. Both of these are preventable in different ways.

Poor health can often be attributable to lifestyle – lack of exercise, poor diet, excessive smoking or alcohol consumption and so on. It might also be connected to poor health care interventions – non early diagnosis of dementia, poor treatment for incontinence, poor recovery programmes following a stroke, lack of advice following a fall, poor foot care, poor dental care and so on. This group of conditions, which have the greatest impact on whether older people need social care help, are rarely given the highest priorities in the NHS. Many health communities in Britain perform badly in these areas but remain unchallenged. So getting both health prevention and health treatment better for older people we could significantly reduce the risks and the need for social care.

Social isolation has its roots in many different causes – from the break-up of families to the nature of mental ill health and the impact this may have on an older person. It often has its roots in communities and how people are integrated and find friendships in older age. The research (mostly from the United States) is clear that social isolation can be tackled  through community solutions,  not state-funded care.

In essence what I am arguing is that we need to redefine the nature of social care by examining the evidence for preventative interventions. We should redefine the way in which people get help – not to be eligible for care but to be helped to live, where possible, without care. The Canadian government commissioned a study at the turn of the millennium which found that people who received a little bit of help from formal social care (home care) were 120 per cent more likely to become dependent on that care and need more of it, compared to a group of older people with similar conditions who were helped to stay away from formal care help. In England a study found that those councils with lower eligibility criteria (ie those who helped people to get care at an earlier stage) had seven per cent higher admissions to residential care than those that helped people to stay out of the care system. What does this tell us about how we would like our care system to be designed? Interestingly, for the past decade as successive governments have tried to put a squeeze on the care costs, the number of older people receiving state-funded support has reduced. In many ways this may not be a bad thing given what has been described above (There don’t appear to be any major studies which look at the impact of this reduction). All of this happened whilst the Labour government was spending considerably more money on care (not just during the more recent austere years).

In the last decade the concept of ‘the expert patient’ has been developed. This needs to be extended into social care and comprises a person and their carer who understand the condition and takes some responsibility with help from the state to manage the condition, constantly striving to reduce the care they need where this is feasible. The state agencies would have to be set up fully to support this approach.

This will require a different workforce – who would need to be better trained, able to address people’s health and social care needs and who would be as a result better paid and rewarded which would also stop the high-turnover, poor-quality care that we now offer older people.

In Britain today we have a means tested social care system. People who have acquired wealth or assets (in property) will have to pay for their care, while those who do not receive free personal care. This seems to fit in with most socialist principles – from each according to their ability to each according to their need! Governments have been concerned that working people who bought their own houses (and acquired wealth), as well as middle-class people who have good pensions, are likely to have to spend this wealth on their care if they are unfortunate enough to need care (which is likely to apply to one in three of us on current rates – which, as noted above, could increase). Why shouldn’t people who have wealth – particularly those in housing who did little to achieve that wealth as prices rose during inflationary years – pay for their care? Older people who follow the advice on prevention and who become experts in managing their conditions – taking exercise and following programmes of help (such as reablement) will be rewarded as they will need less care – will not be given a guarantee of so much care which much of our current models are heading towards.

I would suggest that a future Labour government with little money to fund the public sectors should consider three major moves. First, to focus the social care system on preventative measures; second to ensure that when the state may have to intervene in people’s lives, that they receive the type of short-term help that will support their recovery, not have a long-term entitlement to care, and, finally, that money is not spent on bringing money (that doesn’t exist) into the care sector to help middle and working England but that any growth goes to pay for quality care in higher wages and a better trained staff at the frontline who should have the skills to deliver the new approaches as described in this paper.

This is an extract from a longer discussion paper on the future of social care.

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John Bolton is an independent consultant and a visiting professor at Institute of Public Care, Oxford Brookes University

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Photo: Social Innovation Camp