The Politics of Social Care Reform in the UK: Delivery, Drift or Decay?

In the seminar on ‘The Politics of Social Care Reform in the UK: Delivery, drift or decay?’, Professor Catherine Needham, Professor of Public Policy and Public Management at the University of Birmingham, put the spotlight on reform and how to understand what has and has not happened in social care over the last twenty years or so in the UK. A core question running throughout her talk was whether social care reform is a problem of policy or of politics.

In her talk, Professor Needham was especially interested in assessing the type and extent of reform in the four nations. She elaborated on this by asking whether the situation could be said to be one of delivery, drift or decay.

She pointed out that the crisis of social care is not the same across the UK. In England, it has been mainly a crisis of austerity, whereas the other countries were not subjected to the same fiscal pressures and Scotland actually increased its expenditure on social care. The challenge faced by Wales, which saw more or less stable expenditure on social care in the period, is to meet growing need in the UK nation with the oldest population and largest number of disabled people. In Northern Ireland, the crisis was at root institutional stasis, caused by the political crisis which saw the decision-making system inactive for long periods of time. The research carried out by Professor Needham and colleagues suggested that both Scotland and Wales prioritised a greater role for the state as a way out of the crisis whereas in England the main response taken was to incentivise the markets and commercial providers to provide social care.

Interrogating the degree of change in terms of whether we could characterise social care in the countries as delivering, drifting or decaying, her research found some evidence of delivery – in the sense of substantive legislative change – especially in Scotland which introduced free personal care for over those over 65 in 2002, and later extended it to working age disabled people. Wales has not gone as far as Scotland but there have been some caps placed on personal spending on social care, with a maximum weekly charge for home care and raising of the means test threshold to qualify for social care. Northern Ireland is the laggard as it has not updated its legislation to bring it into line with the other parts of the UK, although there have also been some changes there, and spending has been increased.

But there has also been a lot of drift, in the sense of lack of action or inadequate response. One example of this is the care cap – proposed by the Commission on the Funding of Care and Support in 2011 to set a limit on how much one should spend on care in one’s lifetime. This was passed into law in 2014 but implementation was delayed and has now been abandoned. The moves towards a National Care Service in Scotland also suggest drift as they have now been abandoned. Another form of drift is that some of the legislation that was passed has been poorly implemented, e.g., the legislation on support for carers and some of that on self-directed support. Professor Needham also offered a detailed analysis of how the four nations compare in terms of indicators of drift: cost problems; polarisation on partisan grounds; the role of veto players who can block change; whether or not the system contains automatic updates (the extent to which there is something inbuilt in the original legislation which means it keeps up to date); the agenda capacity and scope of the government’s authority; and uncertain outcomes.

What the research found was that England had all of the elements that might block change, including a strong role for the Treasury in deciding on spending. Scotland had fewer of these drift factors up to 2022, but in the period since then, with the resignation of Nicola Sturgeon and political turmoil, it has started to experience blockages for reform (hence the abandonment of the National Care Service). Wales needed more time to get its institutions going and struggled with things like agenda capacity, but has been able to move closer to Scotland. Northern Ireland has generally suffered, although it has invested more in social care, helped by automatic uprating of spending because social care and health are considered together for budgetary and other purposes.

Professor Needham also considered what drove the situation in the four nations: ideas, interests or institutions. She found that all four nations were striving (more or less) for similar things, like wellbeing and fairness, redistributing the cost, making social care more person-centred, integration with health, etc.

However, they were doing it in slightly different ways. The analysis of Professor Needham and her colleagues was that – across all the nations – not enough attention was given to the policy mix. Trying to make all the changes at once is difficult and it also causes interactions and knock-on effects that are difficult to predict. Interestingly, Scotland approached reform sequentially, whereas England and Wales had big set piece social care legislation, like the Care Act 2014, which did a bit of everything. Professor Needham underlined the point that not enough attention was given to tensions in the policy mix, in particular between whether the goal is to make social care more differentiated, more person-centred and more locally produced, or more standardised, regulated, consistent, safe, and integrated with the NHS.

Turning to the question of politics, the presentation drew attention to political institutions and whether they have the agenda-setting leeway to make the kind of commitment needed for reform. Scotland had the most legislative leeway and also an environment where there was a high degree of consensus. Wales had some similarities to Scotland, although with less legislative scope and institutional capacity to make change. In England, the agenda capacity is difficult and constrained, because of such factors as Brexit, the impact of COVID-19 and an adversarial political context. Professor Needham made the interesting point regarding England that, at least in recent years, incumbent governments have been engaging in a form of self-sabotage – hence reform was blocked not by political opponents mobilising but by the Treasury and parts of the Conservative Party.

Turing to decay, real doubts can be raised here. It was said that countries cannot have a flourishing care ecosystem with the current pattern of underspending and selective resourcing of different parts of the ecosystem. That said, there are many good things on the statute books already. Professor Needham cited the Care Act 2014 as a very strong piece of legislation. Professor Needham suggested that if policymakers were more of aware of some of the drift factors, there might be better tactics around care policymaking. And there are lessons to be learned from the way reform has been approached – for example, there may be some advantages in doing what Scotland did in the period up to 2022, that is, undertaking changes more sequentially.

Among the questions raised at the discussion were the following:

• In the context of the government’s announcement that it plans to set up an independent commission on social care, chaired by Louise Casey, the question was raised of whether commissions can deliver results. Other contributors voiced difficulty in understanding the decision to appoint a commission that will not report before 2028 given the urgency of social care reform.
• The question was raised on whether the public’s strong attachment to – even lionisation of – the NHS is actually a barrier to addressing the complexities of social care. If so, perhaps we need to rethink our approach to both the NHS and social care and the endeavour of reforming social care.
• Another matter raised was whether public opinion and in particular the ambivalence in public opinion about social care is another factor blocking reform.
• There were a number of comments on the practical difficulties associated with accessing social care services. Both information problems and the difficulty of getting services were raised.
• There was some discussion also of proposals to integrate health and social care. The differences between proposals to integrate care and the NHS, and proposals for a distinct national care service were underlined.
• Another matter discussed was why the four nations of the UK do not turn more to each other for lessons about how to reform and improve social care. In particular, England and Scotland seem not to reference each other much.

 

Professor Needham’s latest book (with co-author Patrick Hall) is Social Care in the UK’s Four Nations: Between Two Paradigms, Bristol: Policy Press.

The following article was also referred to in the presentation:

Catherine Needham and Patrick Hall (2023) ‘Dealing with drift: Comparing social care reform in the four nations of the UK’, Social Policy & Administration 57, 3: 287-303.

 

 

Professor Mary Daly, Green Templeton College Governing Body Fellow