We all strive for a happy and fulfilling life. We should all have the support we need to live one. Many of us can live the life we want without much, if any, help. Others may need a great deal, from a range of sources including family, friends, neighbours, community and voluntary groups, and statutory services. What matters most is that everyone can exercise their right to opportunity, independence and control.
Too often adult social care is seen as an adjunct of the NHS, existing simply to relieve pressure on hard pressed acute services. While it is true that social care and the NHS are inextricably linked, it should be seen an essential service in its own right and the people who work hard to deliver the service should be seen as just as valuable as staff in the NHS. It helps people with life-long disabilities, those who acquire disabilities during adulthood, older people with care and support needs and unpaid carers of all ages to live their lives with dignity and in the way they see fit. But it is more than that. It creates services and partnerships – particularly with the voluntary sector – that help strengthen our communities, it allows the NHS to focus on what it does best and it is important for the future of our economy and national productivity; as the Government’s own Industrial Strategy acknowledges, helping people to live independent lives and continue to contribute to society will create “an economy which works for everyone, regardless of age”.
People working in local government care passionately about adult social care and take pride in the role it plays in supporting people’s lives and improving their outcomes. With the right level of funding, councils can continue to make a positive difference to people’s wellbeing. With the right level of freedoms and flexibilities, they can work with health and community partners to drive local action across the public, private and voluntary sectors to reshape care and support around the needs of individuals and in the communities they cherish. With the right training and career opportunities, good quality staff can be attracted to the sector and, as importantly, stay in it. Adult social care has a central role to play in this. But it is also embedded in a wider network of local government services and functions which promote health, independence and wellbeing: all council services contribute to health and wellbeing.
Whilst councils and their partners have a strong story to tell on improving people’s wellbeing, progress to date is now unquestionably at risk. Local government has kept the worst consequences of austerity at bay in recent years but its impact is now catching up with councils, threatening services that improve our lives and our communities. This is certainly the case with adult social care and the service now faces a funding gap of £3.56 billion by 2025. This must be closed as a matter of urgency. If it is not, we will see a worsening of the consequences of funding pressures we have seen to date. These include fewer people being able to get the high quality care they need, providers under increasing threat of financial failure, and a disinvestment in prevention driven by the requirement to meet people’s higher level needs. In particular, funding pressures on social care have severe consequences for the NHS, increasing demand on hospitals and more costly acute care. Of course, this is a two-way street and what the NHS does or does not do can impact equally on social care. Reductions in services such as incontinence treatment, stroke rehabilitation and NHS continuing care increase pressures on social care. We know these problems are only going to get worse as demand grows with the needs of our ageing population. The question of how we pay for adult social care for the long-term is therefore getting even more urgent. The fact the question has remained unanswered for at least the last two decades shows the scale of the challenge.
In part, that difficulty stems from a lack of awareness amongst the public of what adult social care is, why it matters and how it is funded. Not so in the NHS, which people intuitively understand, both morally and operationally. By paying our taxes we pool the risk and cost of treatment we may need if we become sick. We pay in, the NHS pays out, free at the point of delivery, free at the point of need. It is a simple equation and a powerful contract between citizen and state.
It is a far less clear cut picture in adult social care. Not all care needs count as ‘eligible’ for support under the legislation, and the amount you have to pay depends on the level of your own financial resource, which itself is treated differently depending on whether you receive care at home or in a care or nursing home. If you have more than what many would say is only a modest degree of savings, you pay for everything yourself becoming one of a growing population of ‘self-funders’ who are largely left to navigate the system themselves and make their own arrangements. Without the right information and support, wrong decisions can be made, personal savings can reduce rapidly and people fall back on publicly-funded care, compounding the pressure on local services.
The situation is often summed up by the simple example of cancer and dementia. Develop the former and the NHS will, in general, take care of you for free. Develop the latter and you risk losing the majority of your savings because you will have to pay for your care. This inevitably raises a host of questions which tend to gravitate towards a broad idea of ‘fairness’. Over the years this has been articulated in different ways, whether it be about people who have paid taxes all their lives, those who have saved and made provision for the future, the importance of protecting people’s housing assets, the opportunities different generations have (or have not) enjoyed, and how we should approach a person’s ability to pay. Fairness means different things to different people, but the level of concern clearly points to a pressing problem that needs to be resolved. The question here is therefore twofold: how can we change the system for the better, and how do we pay for the changes involved?
Even answers to these questions will not bring about the change we need. Securing the long-term financial sustainability of adult social care is of course important. But the benefits of sustainable social care will be even greater if our wider care and health system can be made to work better as a whole. This requires a fundamental rebalancing of priorities – moving away from treating long-term conditions and illness caused by ageing and lifestyle factors and moving towards community-based models of both early intervention and support. There are many potential benefits of health and social care working more closely together and the role councils can play in commissioning, particularly in terms of NHS community-based services integrating with adult social care. It could also help to manage pressures on public spending more effectively. This would help maximise people’s health, wellbeing and independence for as long as possible, and continue to take a whole-person and whole-family approach to those who develop support needs.
We have many of the key ingredients that are needed to help bring about this shift and focus investment in low cost prevention and support to help bend the demand curve for high cost health care. Under councils’ stewardship we have a better performing and more cost effective system of public health. We have significant new funding for the NHS. In health and wellbeing boards we have a means of joining up clinical, professional and service user voices. We have led the way in re-designing services with – not for – citizens, and we work imaginatively with provider organisations and the third sector. Most importantly, we have democratic accountability through local councils. It is clear we are not starting from scratch. The question here is what level of change is needed to realise the full potential of each of these components?
Through this green paper we want to open up the debate on the core questions outlined above. Our focus in this work is people, and councils across the country want to rise to the challenge and do our bit to make sure people get the care and support they need to live the lives they want. We know that driving continuous improvement amongst councils is just as important as bringing about changes required in other parts of the sector. Whether that is improving our performance, working better with our health and community partners or taking greater responsibility for leading change locally; councils can do more and are committed to doing so. We will need to take risks, scaling up the most successful of the many innovations we have developed and supported. And we know there are no easy answers and that any additional investment must deliver real benefits for local people and communities. This is particularly true for people from black, Asian and minority ethnic backgrounds and other excluded groups who do not yet enjoy equal access to social care consistently: delivering on equalities will be a key test of any new system. The stakes are high. A failure to be bold today will impact on people, our communities, our hospitals and our economy tomorrow and for decades to come.
Our green paper deliberately steers clear of pushing particular solutions at this stage. Instead, it articulates why this debate is so important, the scale of the challenge and the sorts of questions we need to tackle to drive the conversation forward. We will work with our many partners to engage professionals, politicians, people who need care and support and the public alike in the weeks ahead, before producing a further report in the autumn that reflects on our consultation findings. We hope this will help shape the Government’s own green paper, moving it more towards actual solutions, rather than consulting on territory that has been covered before.
Chapter one of our green paper sets the tone for the remainder, starting with the most important voice in the debate: the people who use services to help them live the life they want to lead. In chapter two we recognise that we are all unique and therefore require different support to fulfil our ambitions. Wellbeing is defined and the role of local government and the wider public, private and independent sectors in supporting this is briefly explored. Chapter three sets out the case for change – why social care matters, how the sector has delivered in challenging times and how it remains committed to doing so, and the scale and consequences of underfunding. In chapter four we explore some of the attitudes and beliefs of the public and other key groups in the debate about the future of long-term funding for social care. We set out a series of options for changing the system for the better before setting out a second set of options for how we might pay for those changes. Chapter five moves the debate along to consider the wider changes we need to see across care and health to help bring out a greater focus on community-based and person-centred prevention. It looks at the role of public health, other council services and those of councils’ partners in supporting and improving wellbeing. Chapter six continues this wider exploration of issues by looking at the nature of the relationship between social care and health, integration, accountability and how the new NHS funding could be used for maximum impact.
 See, for instance, https://www.lgiu.org.uk/wp-content/uploads/2012/04/Independent-Ageing.pdf