Andy Burnham has made it clear in his first couple of weeks in office that his main focus is not on fixing the problems in the NHS created by 16 years of underfunding and underinvestment, but on the related, but much more complex and contentious issue of adult social care.
It’s clear to (almost) all that an improvement in social care and in community health services are both a vital part of resolving the capacity crisis in the NHS: but they are also important issues in their own right, and it would be wrong to view social care as merely a subordinate service to the NHS.
It’s worth recalling therefore why social care is in the state it is in: and what happened to the largely effective and popular services that used to be provided by social services departments.
Today’s social care “system,” insofar as it is a system at all, is the outcome of decisions taken and driven through by Margaret Thatcher’s government in the final few years of her reign at Number 10.
She was horrified by the mounting cost of policies introduced in her first and second terms, which meant long-term care (especially for older people in nursing and residential homes) was funded as an individual entitlement through Social Security.
Business entrepreneurs with an eye to a profitable investment had seen that private nursing and residential homes offered an attractive proposition; the number of homes and places rocketed during the 1980s (nursing home places increased from 18,000 in 1982 to 150,000 in 1994; private residential home places expanded from 44,000 in 1982 to 164,000 in 1994).
Booming sector
Nursing homes (which have always been privately run – whether for profit or non-profit) had become a major area of business growth. In 1979, it cost the DHSS £10m to finance 11,000 clients in nursing homes. By 1993, 281,000 people were receiving state-funded care in private homes, at a cost of £2.575 billion.
Health authority and hospital chiefs had also spotted that this was an ideal way to shift the bill for caring for an expensive group of long-stay elderly patients from their cash-limited NHS budgets onto social security.
By the end of 1986, the Audit Commission was drawing attention to the scale of this spending, which was running out of control. Thatcher’s Secretary of State Norman Fowler called in Sainsbury managing director Roy Griffiths to conduct an inquiry to investigate ways of slashing public spending on what was then termed “community care”.
Griffiths, whose report ‘Community Care, Agenda for Action’ was published in 1988, predictably focused not on the whole of community/social care (which includes significant spending on support for people with physical disabilities and mental health as well as services for the frail elderly) but only on the parts of it which offered the chance to replace public funding with means-tested charges.
These were the provision of home help (“domiciliary”) care and long-term residential and nursing home care for older patients – many of whom Griffiths enthusiastically noted had pension lump sums and savings, as well as houses and other assets that could be raided to pay for their own care.
3-tier community care
To take advantage of this meant effectively detaching elder care for middle-class families from the welfare state. The wealthy minority, like Griffiths himself, have always been able to look after their own interests and stay clear of any state involvement.
Mental health and disabilities (where patients often have little or no income or assets) were therefore largely ignored by Griffiths, who was also less than interested in the care of poorer pensioners in rented accommodation.
His plan was an unashamed 3-tier solution, one tier for the very rich – not discussed at all; another (effectively denying any choices) for the poorest; and a new third tier focused on ensuring that “those able to pay the full economic cost of community care should be expected to do so.”
The most urgent need was therefore seen as separating long-term elder care from the NHS, where the principle of treatment provided ‘free at point of use’ continued (and still continues) to command overwhelming public support.
The obvious answer was to shift responsibility for all but the most pressing medical needs away from the NHS and give it instead to local government social services departments, where the possibility of levying means-tested charges for services had never been abolished.
Liability for local government
Thatcher, who famously detested local government, was persuaded by this argument to agree to handing over a major new responsibility (more accurately a new liability) to local authorities.
They would have to be the ones to do the means-testing, decide the charges, and tell older people and their families that their savings had to be spent and that their homes, if owned, had to be sold – to pay for care in care homes that almost nobody chose or wanted.
To prevent any possible expansion of the public sector provision of long-term care, and maximise the opportunities for private profit, the switch of responsibility came with tight new restrictions on how the central government funding of community care could be spent. The vast majority of it (85%) had to be spent on commissioning private care homes and private home-care contractors.
That meant many authorities had to divest themselves of their home help services, sell off residential homes, and commission private contractors. Councils’ role as providers was to be reduced to the barest minimum, filling in where the private sector chose not to provide; instead, they were to become “commissioners” of community/social care, which in turn became a chaotic marketplace rather than any kind of coordinated service.
These changes were included in Thatcher’s final fling of “reform” to the NHS, the National Health Service and Community Care Act, which received Royal Assent on 29 June 1990. It also restructured the NHS by introducing a new “internal market”, creating self-governing NHS Trusts and separating healthcare purchasers from providers.
The NHS changes (which had not been mentioned in any manifesto) were pushed through with urgency. However the Community Care changes – which were potentially an electoral liability had the opposition had been bright enough to realise it – were deferred until 1993 (after the next election).
Vanishing geriatric beds
Most NHS acute hospitals, forced into competing with each other and minimising overhead costs and loss-making services, were eager to get rid of the thousands of long stay (“geriatric”) beds. They hoped instead to focus on the treatment and discharge of acute patients.
Geriatric bed numbers began to fall sharply, from 51,000 in 1988 to 40,000 in 1992-3 (a 21% drop in five years), to 28,000 ten years later in 2002/3 (a drop of 32%), and by another 25% to just 21,000 by 2010.
From there on the NHS statistics ceased to register specialist elder care (geriatric) beds at all: the numbers of any that remained were merged into the new category of “acute and general” beds, which seems to have pretty much levelled out at around 100,000 in England for the last few years.
However NHS trusts were not the only organisations facing fresh financial pressures. Budgets of local authorities were also squeezed, and as a result the quantity and quality of social care was inevitably pared back – towards the bare statutory minimum.
From 1994 onwards many councils adopted increasingly stringent “eligibility criteria” – to limit the numbers of people who could access any form of support. Thirty years later these now mean that people with ‘low’ or ‘medium’ levels of need are unable to access any early intervention: any idea of proactive or preventative support to prevent people declining further has been abandoned.
But there has also been a growing toll of people in need of care who cannot get it – with the added random postcode lottery factor of variation between local councils and their social services. This stands in stark contrast to a decade of verbal references to “integration” and “seamless” links between health and social care.
Growing gaps
Age UK’s annual reports on The State of Health and Care of Older People in England have charted the growing gap between the increased numbers of patients aged 75-plus and the much smaller increase in numbers accessing social care support.
The statistics also show that the local authority ownership of care homes had fallen to just 2% by 2024, and the for-profit private sector (with players now including even more predatory and exploitative Private Equity companies) has largely taken command of a very unequal and increasingly chaotic market.
In April the Centre for Care warned in an important report that the adult social care sector in the UK is also facing a growing workforce crisis:
“With 111,000 unfilled roles and an ageing population, the sector has a high demand for its services and is struggling to recruit and retain staff to meet these needs.”
Moreover, as a workforce that has long relied on migrant workers and ethnic minority staff, social care is only set to get worse as long as successive governments maintain austerity limits on spending, refuse to improve pay and working conditions, and pander to right wing and racist calls to further restrict immigration:
“The sector is caught between tightening immigration controls and a domestic workforce that is insufficient to fill the gap. The authors argue that restricting visa routes alone will not solve the problem. Without meaningful pay, funding, and working conditions, the sector faces deepening instability, and the people who depend on care services will feel the consequences.”
Present problems
Andy Burnham has gained some credibility by his early and apparently firm commitment to at least attempt to tackle the chronic problem of social care. But whether he (or his cabinet, or the Labour MPs who would have to vote for it) will have the courage to recognise the problem, and change the flawed system that was created in the 1990s by the biggest-ever privatisation of NHS services, is still open to doubt.
Unlike other privatisation measures, which only awarded time-limited contracts to private firms, the wholesale closure of NHS geriatric beds after 1988 gave control and ownership of the private nursing home facilities that took their place to the private sector.
This comprises many small-scale operators, many of whom are struggling to generate any profits and looking to get out of the market (so maybe are now open to offers for the state or local government to take them over, instead of private equity) but also a number of much larger private chains and companies backed by private equity – which are siphoning out an estimated £1.5 billion a year of taxpayers’ money in profits.
Earlier this year the Cooperative Party published an earnest study of the situation in social care which (predictably) argued that non-profit cooperatives rather than grasping private corporations should be the way forward – but also admitted the key stumbling block to any publicly-funded alternatives: they will have to spend more to patch over the damage done in the past 35 years:
“The persistent underfunding of social care has been the biggest barrier for a better care system. It is very hard to provide sustainable care on the per hour fees provided. Local authorities provide insufficient amounts to pay the living wage and cover training costs.”
The same report also emphasised that the worst gaps and failures in care are in the most deprived areas, making the political challenge even greater.
Paid for by NHS savings?
That’s why it is alarming to see Andy Burnham pre-empting the findings of Louise Casey’s review of social care (which has been brought forward to next year) by announcing in public that some of the funding for the reform of social care can come from greater efficiency in the NHS.
This completely misunderstands the way in which social care impacts on the NHS. The most high- profile issues in the NHS are the prolonged waiting times in A&E – with still rising numbers of 12-hour trolley waits for the most seriously ill patients – and Labour’s manifesto commitment to reduce the waiting list.
Improved and expanded social care, coupled with improved internal systems to deliver prompt paperwork and drugs to take home, could indeed offer the possibility of more speedy discharge of patients clinically ready to go home from hospital.
But this is likely to require up-front investment: and it will by no means deliver any instant cash savings to the hospitals. It would allow the more rapid admission of emergency patients who currently wait hours in corridors or A&E: and insofar as additional beds are freed up, it will also allow increased rates of elective care.
So the beds would not be left empty: they would be more effectively used. They would still require staff (clinical and non-clinical).
It’s worth noting that improving social care in some areas also requires the NHS to have the capacity to respond promptly to the urgent medical needs of frail older patients when needed, as well as improved GP and community health support.
Improving social care would also require widening access to support for millions of medium and low needs patients who currently receive little or no care unless and until they face a crisis situation – such as a fall, a heart attack or stroke. There is no way any relatively marginal cash savings from the NHS could cover the costs of this rebuilding and expansion of the home help and other services that have been run down and privatised since the 1990s.
And investment in improving all aspects of social care (including mental health, children and support for disabled people) is needed up front to make it happen – long before any effects or improvements are felt in the NHS.
Cost of going forward
As Burnham refuels the ongoing debate on the way forward for social care, he has already tacitly conceded that the cost of doing it properly is far greater than he is willing to go. But if he rejects more radical answers, he faces tough choices on more partial measures, and how they should be funded.
The mess has been with us, and getting more messy as successive governments have ducked the question and broken promises to clear it up, for almost 35 years.
But one thing is clear: whatever answer Burnham arrives at in the end, we can be sure it won’t be paid for by efficiency savings in an already struggling NHS. More money will need to be spent.
And if more money is to flow in to social care, it would surely be madness to allow much of this to flow straight out again, into the coffers of private equity companies leeching on care homes and profiteer contractors in home care.
It’s worth recalling that in the midst of the shocking care home death toll in the Covid pandemic even a Tory peer was brave enough to call in 2020 for the nationalisation of the care home sector.
The big underlying question is whether a Labour government will choose to load the extra costs on to “hard-working people”, or be bold enough to find ways to force the corporations and super-rich, who for far too long have been the main beneficiaries of tax cuts and practitioners of tax avoidance, to pay a fairer share.
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