40 POLITICAL INSIGHT • APRIL 2017
Crisis in Social Care
Axel Kaehne examines the options for tackling the
UK’s social care crisis.
As the NHS stumbled through
another winter crisis, the situation
in social care has come under the
spotlight as well. But so far, the
social care crisis has resisted simple solutions. So,
what is the problem with social care? The crux
lies in unfavourable demographics, an aging
population which contributes to rapidly rising
demand (see graph).
The number of people over 65 is to increase
by 21 per cent by 2025. Add to the mix that
social care funding, which makes up over half
of local authority budgets, has been cut by up
to 40 per cent in some localities, the magnitude
of the challenge becomes clear. But it is not just
reduced funding that has left social services
teetering on the edge. As medical treatments
become ever more sophisticated – and
expensive – pressure is growing to administer
much of what used to be done in hospitals
through community care. To implement this
shift to community care social care will need
more money, and a lot of it.
With the exception of Northern Ireland, adult
social care funding comes from two sources:
local authorities and individuals contributing
to services from their own pockets (in England,
capped at £75,000).
Finding a new source for additional funding
for social care remains tricky. Council tax only
accounts for about a quarter of local authorities’
budget, so even the most ravenous council tax
increases will not plug the funding gap in social
care. A second option could be to transfer NHS
money to social services. As more people are
cared for in the community, so the argument
goes, NHS hospitals would be able to free up
resources that could be spent on social care. Yet,
that neglects the iron law of health care costs
in the developed world: whenever medical
advances have led to improved efficiency, new
treatments have eaten up potential cost savings.
This leaves politicians with only one option:
significant reform of the way in which social
services are organised and delivered in the
UK. Devolution doesn’t make this task easier,
as the UK has now effectively at least four
different social care systems (England, Wales,
Scotland and Northern Ireland). In addition, the
devolution of health and social care budgets
to Greater Manchester, Sheffield, Cornwall and
others will diversify the organisational landscape
even further in England.
With this picture of horizontal (devolution)
and vertical (split between hospital and
community providers) fragmentation, the
politics of reform look intractable. Whilst there is
an emerging consensus amongst Westminster
parties that additional funding for social care has
to be found, there is a lack of viable proposals.
One option would be to add one per cent to
National Insurance payments or to income tax
to pay for social care. So far, the Conservative
government has shown little appetite to increase
taxes, however. Establishing a separate social
care insurance commands equally little political
support. Another suggestion is to divert funding
to social care from workplace pension pots,
something that has become viable as people
are now auto-enrolled in pensions. Yet, similarly
it would undermine how social services are
perceived by tax payers, as something they
are entitled to. Consequently, it has found few
Integration between NHS and social care may
offer some hope. However, NHS and social care
operate within different financial systems. NHS is
universally tax funded. Social care is means tested.
There is also long standing resistance amongst
social services against the expansion of the NHS
into community provision, and the encroachment
of the medical model that would come with it.
What remains is the unique solution that
has been championed in this country for
decades – muddling through. Hoping for the
best is popular not because anyone likes it, but
because it is politically the most expedient form
of incremental change in social care. Social care
has no single institution (like the NHS) with a
strong voice in the national debate. Scandals,
where they happen, are localised, unlike scandals
in the NHS which are perceived as systemic.
Social services also operate under a dispersed
accountability model, where responsibility is
split between funding (central government)
and delivery (local authorities). This encourages
local politicians to blame Westminster, and vice
versa. Crucially, however, users of social care have
little power. They are recipients of a service that
is defined as a basic entitlement, making them
consumers without choice.
Last but not least, rationing social care has
been a hallowed tradition in the UK for decades.
Eligibility criteria have long been used by local
authorities to match supply to demand. So,
muddling through may be all we have.
Axel Kaehne, Co-chair of the think tank
GORWEL and Reader in Health Services
Research at Edge Hill University.