The fantasy of 'social care'

Many years ago, my late father-in-law developed a form of dementia. He was a kind and sociable man, but his memory and his ability to care for himself steadily deteriorated. My mother-in-law found it increasingly difficult to manage him at home, and he was referred by his GP to a rehabilitation hospital. After various tests, they recommended he be placed in a nursing home. We went through a painful search for a suitable home, until a nearby one was located. There was very little help from the local Social Services Department, apart from their completion of a financial assessment. My mother-in-law was not eligible for financial assistance from the local authority because she had a limited amount of savings. There were therefore substantial fees to pay which would have almost completely depleted these savings had my father-in-law not died within a few months. 

A few year’s later, my mother-in-law’s health declined. She had become physically-frail and depressed. She fell over (‘had a fall’) one day and was admitted to a local hospital for treatment of her leg ulcers. The hospital had a warm and caring atmosphere and provided the equivalent of good hospice care until she died after a few weeks. Because this was an NHS hospital, there were no fees to pay. 

This is a common experience for many families in England, and illustrates some key problems with our health and social care services. The first of these is that the boundary between ‘healthcare’ and ‘social care’, is not based on need but on who pays. A person with a diagnosed and acute physiological illness is usually treated as ill and receives free hospital or domiciliary health services. Some one with a chronic physiological disorder or a psychiatric disorder such as one of the dementias is categorised as the responsibility of local authority social care services and is usually required to meet all or a substantial part of the cost. Although dementia is an illness and intensive nursing care was recommended by the NHS, my father-in-law had been passed from ‘heath care’ to ‘social care’. 

The boundary between ‘heath care’ and ‘social care’ has shifted in the last few decades because the NHS has progressively withdrawn from providing long-term inpatient care. Hospitals which once housed infirm elderly people and people with mental disorders have long since closed. This has been presented as a move toward ‘care in the community’, but the reality is that NHS units which were free at point of use have been replaced by residential and nursing homes operated by private providers and which charge their occupants. In other words, it has been an exercise in privatisation, with the cost of care shifted from the state to chronically sick people and their families. 

Successive governments have avoided dealing with this problem, largely because of its complexity and the cost (both political and financial) of resolving it. There are two contradictory problems with cost. The first is that the need for expensive long-term ‘social care’ strikes individuals and families at random. It thus resembles the cost incurred by people with severe acute disorders who receive intensive hospital treatment. The most common political response is to propose a lifetime cap on the payments made for ‘social care’, with the remainder to be met from public funds. This was proposed by the Conservative Government in 2021 with a lifetime cap set at £86,000, but implementation was delayed and eventually cancelled. The second problem with cost is the grossly inadequate funding for ‘social care’, whether this comes from public or private sources. Funding for social services has fallen by 22% since 2010, taking into account the rise since that date in the number of elderly people. Local authorities have consequently frozen the fees they pay to providers of nursing or residential care. The private providers have responded by increasing the fees they charge to those residents who do pay for their own care, and by cutting costs. They have done so by following the old institutional strategies of building ever-larger institutions, keeping staffing levels at the legal minimum, and paying staff the minimum wage. This has led to high staff turnover (about 30%/year), a high proportion of unskilled staff, and probably a poor quality of care.

These two problems with cost are incompatible because setting a cap on individual contributions will not by itself increase overall funding for ‘social care’, and may have the opposite effect. Governments may respond to the cost incurred in paying for the lifetime cap by cutting back or at least freezing central funding for local authorities. In the end, an effective and fair system of care for chronically-sick people will require a substantial increase in public funding. This might take the form of an additional scheme of social insurance combined with an annual or lifetime cap, as used in France and Germany. Or the NHS could once again accept responsibility for the care of people with dementia in their final years. Either way, this will not be easy to implement. Much of the the electorate has slipped into a fantasy land where they demand better public services and lower taxes.