“You only hear negative things, like people being abused in care.” That comment, by a participant in a major research project on public perceptions of social care, goes to the heart of the image problem that undoubtedly hobbles any attempt to build a popular campaign on the sector’s behalf.
But there are other important reasons for social care’s continued failure to punch its weight in the political and policy worlds – a failure demonstrated all too clearly by ministers’ casual excuse of repeated delays in publication of the promised green paper on reform. And if the sector is ever to break free of its subordinacy, it has to understand what they are.
Creating a strong voice
I have been writing about social care for the Guardian for three decades. When I first took on the brief, as part of a wider correspondent’s role then called ‘social services’, I was puzzled about where the sector’s leadership lay. It took a long time for me to realise that it didn’t lie anywhere.
It’s not an original observation to say that the lack of a single, strong voice for social care is a big part of its difficulty. So the fact that the sector has not addressed the issue, or certainly not come up with any solution, should be worrying. Yes, there are healthily competing interests among providers, commissioners, users’ and carers’ groups and regulators, but it ought not be beyond their collective wit and artifice to devise something that articulates a common cause.
Sadly, recent evidence suggests it may be. Attempts were made in 2016 to launch a ‘social movement for social care’, intended to build pressure for a game-changing funding breakthrough in the 2020 spending review, but the initiative petered out. The threefold aim had been to ‘lift the veil’ on social care, raising public awareness of what it is and popularising what it does; to make the link between social care and a sustainable NHS in terms politicians could understand; and to mobilise a broad-based campaign that put social care squarely on the political agenda.
Arguably, significant progress has been made only on the second of these: the umbilical link between social care and health is probably better appreciated now than it was three years ago. But the other goals remain wholly unrealised and the underlying premise of the social movement idea – that social care is fundamentally a ‘weak brand’ – remains as true as ever.
Why did it get nowhere? The sudden death of Harold Bodmer, president of the Association of Directors of Adult Social Services in 2016 and a key driver of the plan, certainly took the wind from its sails. And there was not exactly a stampede to chip in the annual £100,000 minimum thought necessary to meet the movement’s costs. But above all, the sector’s many and various cats proved unherdable.
Changing the narrative
One key tension in those tentative discussions about a social movement was over the preferred narrative, specifically around the balance between a basic message calling for more funding for the system as is, and a broader vision of what could, and should, change to improve quality, outcomes and user/carer choice and control. That difference of approach persists among the sector’s stakeholders and has flared into the open over the past 18 months with the emergence of Social Care Future (SCF), a group which describes itself as an ‘informal volunteer-run platform for all wishing to bring about major positive change in what is currently called “social care”’. At the National Children and Adult Services Conference in Manchester last autumn, SCF challenged the social care establishment head-on by organising a vibrant rival event nearby.
One of SCF’s key tenets is that anything done to promote the sector, or set its future course, must involve the people who receive care and support. But another is that the conventional narrative is setting wholly the wrong tone because it is couched in negative concepts. As Neil Crowther, one of the leading figures in the group, has written, debate is, ‘dominated by the language of death, bed-blocking, tax, unfairness between young and old, losing our homes, unaffordability and crisis’. Given such fatalistic thinking, he argues, it is hardly surprising that governments of the past 20 years have struggled to win public engagement and support for a long-term funding settlement.
The term you hear most often in SCF discussions is that social care must ‘reframe’ the debate – painting a picture in positive colours, putting the onus on what good social care can do to transform people’s lives and breaking away from its image of a safety net that you turn to only in extremis. But to do so, it warns, providers and commissioners must accept the need for radical change.
It is without doubt a tall order. But Crowther makes the point that the poor public understanding of social care is, paradoxically, a singular opportunity to define and articulate a new story. That research project on public perceptions, where the participant said you only hear of things like abuse, concluded that ‘people generally know very little’ about how the system works. Conducted last year by IpsosMORI for the Health Foundation and The King’s Fund think tanks, it found that even people who had direct experience of services struggled to grasp how they were delivered and how decisions were made.
At the 2017 general election, of course, Theresa May discovered to her cost that many people had no idea they might have to sell their homes to pay for care in old age. By inadvertently highlighting the existing rules in an attempt to promote what was in many respects a sensible reform set out in the Conservative manifesto, she came a cropper. Many politicians seem in no hurry to revisit the accident scene: when leading North Yorkshire provider Mike Padgham recently wrote to all 650 MPs calling for urgent action on funding, he received fewer than 10 replies.
Perhaps we should blame Beveridge. When the welfare state was created in 1948, social care was pretty much left out of the mix. But at the time, male life expectancy was 66 – few people lived long in retirement, and disability was seen as a medical issue.
As a result of having no dedicated policy silo, the sector has grown haphazardly. Responsibility is split across Whitehall, with the Department of Health and Social Care (only rebranded as such last year) having the policy lead, but funding being channelled through the local government ministry. Welfare benefits, which logically should be wrapped in to any consideration of people’s support needs, sit with a third department. There is no dedicated policy institute for the sector, the Social Care Institute for Excellence having perforce moved into consultancy; research is fragmented, slow and too often out of kilter with frontline needs; and, it has to be said, efforts to achieve a united front among stakeholders are hampered by antipathy towards, and suspicion of, larger corporate providers and the role of venture capital.
Seizing opportunities to adapt
Who will speak for social care? In the March CMM, consultant and commentator John Kennedy argued that the ‘only hope’ rested with the Care Quality Commission because it has the ear of Government. While that is true, and the regulator has been dancing on the head of a pin for a long time now with its repeated warnings of the sector being near, at or partly past a tipping point, there are other reasons for modest optimism.
The past couple of years has seen a clear and growing interest in social care on the part of the health think tanks, not just the Health Foundation and The King’s Fund but also the influential Nuffield Trust. They increasingly take a welcome perspective of the health and care system as a single whole and are potentially powerful advocates. The energy and positive disruption of SCF and associated groups like Think Local Act Personal is also something to applaud, and to harness, and providers deserve much credit for having embraced initiatives to reach out to the wider world, such as Care Home Open Day and Your Care Rating – although the latter has lost the novelty it had on launch in 2012 and probably needs a rethink.
But the best cause for hope that social care will eventually win the profile it merits is a slowly dawning awareness of the sector’s sheer size and economic contribution. Thanks to Skills for Care, which has done much of the heavy lifting on this on its own initiative, we can say conservatively that social care is worth more than £40bn to the UK economy, it is growing faster than most other sectors and it already provides jobs for 1.5 million people in England alone. Simple demographics mean demand is going only one way.
Some regions, notably the West Midlands, have seized on this and are now treating social care as a key driver of the local economy, helping to map demand, plan expansion and organise recruitment and training. In doing so, they recognise an imperative to rethink ‘business as usual’ economic development. To play its part, and to take full advantage of this emerging opportunity, social care will need to rethink business as usual too. Can it do so?
What do you think should be done to improve public perception of care? Where does the responsibility lie? Express your thoughts and share feedback on this article by commenting below.