Four years on from the promise to “fix” social care, why does reform remain out of reach?

It has been four years since Boris Johnson pledged “to fix the crisis in social care once and for all”.

This promise increased optimism that progress could be made on an issue that has a profound impact on the quality of life for many people but has proved a challenge too far for successive governments.

However, as has been so often the case, crucial social care reform has remained elusive.

The levy which was set to pay for reforms has been abandoned, while a cap on costs to alleviate the punishing financial burden of adult social care is now delayed until after the next general election.

Prime Minister Rishi Sunak continues to stress his commitment to reform but social care appears in limbo once again, with a workforce crisis entrenched and limited provision out of step with rising demand.

There is no other policy debate that more regularly features the accusation that decision makers have “kicked the can down the road”.

So why is social care handled this way?

It is a vital frontline service that has the capacity to transform many lives now and in the future. Most of us will need to draw on some form of social care support if we are lucky enough to live into older age.

Many impassioned speeches have been delivered by advocates on the urgent need for reform and the suffering caused by inaction.

Numerous reports have made a powerful case for change. Harrowing TV documentaries have shone a light on the struggles of people living with disabilities caused by failings in the system.

No politician argues that reform is not necessary, or that such support services are not crucial to the wellbeing of individuals and communities. The moral imperative for improving social care is clear.

There is also consensus that social care plays a pivotal role in the wider health system by alleviating pressure on the NHS.

However, social care still suffers from under investment and is treated as secondary to many other areas of government spending. 

One factor causing this could be perceptions of public opinion.

Polling of voters on what the Government’s spending priorities should be consistently shows the NHS, education and crime are considered the most important.

Local government, which organises and funds social care though council budgets, lags well behind.

A poll conducted by YouGov published on June 26 found 14% of people think the Government should spend more on local government. This compares to 74% who said the NHS should receive more funding.

Therefore, it is not surprising that decision-makers react accordingly and a cycle of limited short-term cash injections for social care are used to prop the current system up instead of large-scale investment in transformation.

This pattern of temporary fixes perpetuates instability rather than providing conditions for long-term strategic reform.

It has been suggested that a misconception among the public over how social care is organised and paid for is the reason local government funding for social care is not seen as a priority by many voters.

It is often said that people believe social care is part of the NHS system. However, there is emerging evidence that public perceptions are changing.

A public survey conducted by the NHS Confederation published earlier this month identified increasing capacity in social care as the most important way of addressing challenges facing the NHS.

Responding to the findings, Matthew Taylor, NHS Confederation chief executive, said: “We’re on the eve of both the NHS 75th anniversaries, which is also the date when social care was set on a statutory footing, but the danger is that while one service – the NHS – is celebrated and lauded, the other – social care – continues to fail while politicians look the other way.”

Another likely reason why social care reform has not been implemented is the adversarial nature of politics.

While all main parties agree social care remains an urgent national challenge, there has been an absence of cross-party collaboration on finding solutions.

Meanwhile, when parties have proposed reforms, political opponents have been quick to respond with emotive critical soundbites.

For example, Labour branded Theresa May’s proposals for social care charges a “dementia tax” ahead of the 2017 general election. Likewise, Conservatives previously accused the last Labour government of seeking to impose a “death tax” over its plans to introduce a levy on estates to fund care.

This political point-scoring on the issue has heightened the sense of political risk surrounding social care and has made embedding consensus on a national challenge near impossible.  

This absence of formalised cross-party agreement on a long-term strategy leaves the issue vulnerable to changes in political leadership, as demonstrated by Liz Truss ditching the health and social care levy during her short spell in No 10.

Camille Oung, fellow at the Nuffield Trust, said the negative framing of social care is preventing reform that will enable people to live “gloriously ordinary lives”.

She added: “At present, attempts to reach this point are hampered by reductionist political and media discourse that often portrays social care as a means to prop up the NHS, talked of as beds rather than people and a drain rather than an investment.”

While this suggests the narrative around social care must change for progress to be made on reform, the way the machinery of Government works poses perhaps the biggest challenge.

Speaking to the Institute for Government recently, Caroline Dinenage, who was a social care minister under Theresa May and Boris Johnson, provided an important insight into why reform could not get off the ground.   

She said: “The problem we had was, of course, the Department of Health and Social Care can come up with a solution, but then that solution has to be backed by both the Treasury and Number 10, and there are no solutions to the challenges of adult social care that do not require huge political bravery and a lot of money. And so, during the time that I was there, we were never able to get it over the finish line.”

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