For people who have worked in UK public policy in recent decades, whether as civil servants, politicians or advisers, there is something wearily familiar, and depressing, about the current debate on the reform of social care. A fair chunk of the period I worked in No10 Downing Street, between 2007 and 2010, was spent on social care policy: on reports commissioned from the Prime Minister’s Strategy Unit, papers drafted by committees of civil servants working up options for cabinet sub-committees, notes for political discussions between ministers, party conference announcements, and even legislation. None of it went anywhere. Cross-party talks were scuppered by the Conservatives, the Treasury dug in against reforms considered fiscally unsustainable, and Labour malcontents in the House of Lords blocked legislation that they thought was partial and incoherent. Nor did it get much better after 2010 – Andrew Dilnot was commissioned to review social care funding, but his recommendations were kicked into the long grass, while local government spending on care services fell under the heaviest of axes.
Why has social care remained unreformed, when other public services have been subject to extensive, often unrelenting change? It is not simply lack of political will, though that has played a part. Nor can it be that the funding and organisation of social care is more complex and difficult to reform than other areas of public policy; pensions’ policy, for example, has been successfully reformed, on a largely consensual basis, in the last decade. The concepts of mainstream public policy analysis – punctuated equilibria, multiple streams analysis, or narrative policy frameworks through which policymakers make sense of the world – do not seem to provide much explanatory help. Instead, we should look to the political economy of welfare states.
The social care system (here taken to refer primarily to social care in England) is staffed by low-wage, largely non-unionised, predominately female employees working for private companies. There are no high-status, powerful professionals, like NHS hospital consultants, in social care – nor strong trade unions organising a high proportion of care staff. The workforce is heavily dependent on EU migrant labour. Services are mostly commissioned from private companies by local government, rather than provided by the public sector itself. Social care was kept separate from healthcare in the 1948 settlement, meaning that it has never benefited from the popular support and protective institutional aura of the NHS. Social care consequently does not generate institutional interests that are capable of powerful political expression: the labour voice is weak; professional vested interests are marginal; there is no national public sector body responsible for the service; and the business interest is uncoordinated.
Older people using social care are not politically mobilised, like parents of school children or NHS patients. Most of us are myopic about our future care needs; we tend not to plan ahead for the care we will need. For those suffering long-term conditions, like dementia, care will be needed for a long time – but for many of us, care services will be limited to end-of-life support of relatively limited duration. We know that we will need a pension for retirement, and health services throughout our lives, but not whether we will require social care. This means that the state is under limited pressure properly to fund and improve care services. In recent months, much of the political concern about social care has been generated by the knock-on impact that cuts to local government services have had on the NHS.
The social care systems of so-called liberal welfare states like the UK, Ireland, Australia and the USA, share many features. They are residual, relying heavily on limited means-tested safety nets, rather than providing universal coverage. Low levels of expenditure on means-tested assistance are funded from general taxation. At the same time, private care insurance is limited (non-existent in the UK case), but nor is there comprehensive social insurance or a compulsory care saving, as is typical of countries like Germany, France, Japan and Korea. Social care systems therefore tend to typify the welfare states of which they are a part: individualised, means-tested and general-taxation-funded liberal systems; universal, tax-funded Nordic systems in which care needs are decommodified; continental care systems that have developed from tripartite-funded (employer, employee and the state) social insurance systems; and East Asian systems in developed economies that have expanded compulsory care insurance coverage as their populations have aged, based on co-funded mechanisms.
Social care has also tended not to feature in Social Investment State (SIS) strategies that have dominated welfare state reform discourses in the UK and elsewhere since the 1990s. SIS conceptual frameworks prioritise employment and human capital investment, and privilege childcare and support for parental employment, over care of the elderly and adults with disabilities.
What then are the prospects for successful reform of social care in this latest round of policy debate? Substantively, the UK is unlikely to pursue the compulsory/social insurance or universal tax-funded reform options that have been developed in other welfare states – we lack the political economic foundations and politically mobilised social group interests for those kinds of reforms. More likely, ministers will tilt towards co-payment models or tax-incentivised private savings vehicles, with a floor of means-tested support. These will be partial and inegalitarian, however, since they do not pool risk across the population, and they tend to squeeze those who have income and assets just above the threshold for means-tests, while enabling those higher up the income and wealth distribution to buy better services, and forcing low-income families to rely on low-quality services – poor services for poor people. Meanwhile, ministers will put just enough funding into social care services to stave off collateral damage to the NHS, as the Chancellor did with an extra £2 billion over three years in his budget.
Pressure for change may depend on the politics of ageing. Turnout in UK elections is heavily skewed towards older voters, who currently form a solid bloc of support for the Conservative government. This demographic political inequality is commonly thought to explain why pensions and benefits for older people have received relative protection in the era of austerity, while inheritance tax is cut and wealth levies (the so-called "death tax") are abjured. Academic research into the politics of age is unfortunately more limited than that into social class or occupational groups (although it is a growing field and interest from think-tanks has been developing). The politics of social care may come to turn on whether the collective interests of older people and their families in the provision of properly-funded, comprehensive services, integrated with the NHS, can trump both the social class differences between them and the lack of broad coalitions of support that currently inhibit progressive social care reforms. For now, Whitehall watchers will not be holding their breath.