CARE MATTERS Podcast episode transcript (automated)
The Care Matters podcast is brought to you by the ESRC Centre for Care and CIRCLE, the Centre for International Research on Care, Labour and Equalities. In this series, our researchers welcome experts in the field and to those giving or receiving care to discuss crucial issues in social care as we collectively attempt to make a positive difference to how care is experienced and provided.
Hello and welcome to Care Matters, The podcast from the Economic and Social Research Council, Centre for Care and the University of Sheffield Serco Research Centre. My name is Duncan Fisher and I am a research associate at the Centre for Care. We are delighted to welcome Richard Humphries as our guest. And in this episode we will discuss Richard's new book, Ending the Social Care Crisis.
This is part of our ongoing series looking at New Literature on care in the book. Richard considers the report a meaningful and enduring positive change for adult social care in England and what we can learn from history and other contexts in this regard. Richard Humphries is a recognised national commentator on social care and health policy is current roles include senior policy adviser to the Health Foundation and Newton Europe and visiting professor at the University of Worcester.
He was senior fellow at the King's Fund from 2009 to 2021, covering social care and integrated care between 2021 and this year. He was a member of the Reimagining Care Commission established by the Archbishop of Canterbury in York and a special advisor to the House of Lords Economic Affairs Committee. Inquiry into Social Care from 2017 2019. Building on a career in social work over the past 46 years, he has worked in a variety of roles, including as Director of Social Service and Health Authority Chief Executive, England's first joint appointment and in senior roles in the Department of Health, working with ministers and senior civil servants.
Richard's new book, ‘Ending the Social Care Crisis’, The subject of this episode was published in autumn 2022. Welcome to Care Matters, Richard.
Thank you.
So, Richard, could you please introduce the book to our audience and tell us what the book's about?
Sure. And thanks, Duncan, for inviting me to do this. It's a great pleasure to be doing it with you, and I hope that listeners will find this helpful and maybe a bit educational as well. So so the book was really born out of a mixture of motivations, really. First of all, I was a bit frustrated that there's lots of stuff written about adult social care, but none of it in one place.
There's lots of pieces, really good pieces of work as articles or research papers, blogs and so on about different aspects of the problems in social care, like workforce or the nature of care services. The need for users to be more involved. But nothing really that pulls it all together in one place. So I've been mulling this over for some time that a need to do something.
Also frustrated that successive governments over 25 years have been trying to sort out social care and have generally failed. But we don't seem to be learning from that, and we just seem to be repeating the same kind of approaches and processes. And a lot of the thinking as well as has been very superficial. But above all, the debate about social care has really been all about negatives, about the so-called burden of care, the costs of care, people stuck in hospital care, homes closing, and nothing about the good that social care can do.
And it seems to me the more I've thought about this, that needs to be the starting point, not the all the difficult stuff and the problem. So the book really is an attempt to set out, first of all, what is social care, What do we mean by it? What does it consist of? And I've tried to illustrate that through the voices and experience of people that have had social care needs and use services.
And how has it evolved over the years. And that throws up some surprise conclusions about the causes of the current problems. What can we learn from other countries about how they have gone about it? But above all, what can we do and how do we need to go about the process of really sorting out social care that avoids the mistakes of the past and really can lead to some enduring change.
So that's in a in a nutshell.
Okay. Thank you very much. And I think that that kind of your final your key point there to the question of what can we do? Certainly something that will we can come back to later in the conversation as and as something stick in of emphasise and discuss further. So just in terms of just to come back on your answer there, you worked in the social care for a long time.
You've been thinking about these ideas, but in terms of the actual process of writing the book and even the opportunity, how did that more practical side of writing a book for you? How did that kind of come.
To the IT? So as I say, I've been thinking about it for some time and I've written all sorts of stuff. I've written articles, the journals, peer review stuff, lots of stuff I published when I was with The King's Son, but never in a book. So I made this was a personal development challenge as well. And then, of course, COVID came.
So lockdown was a great opportunity to kind of to spend the time on it. But actually, the actual trigger that finally kind of caused me to begin the process was the personal experience I had in sorting out care for my late father, which I talk about in the book. But it illustrated for me both the best and the worst in our current social care system and the worst aspects and the nature of, say, of the struggle to get to get good care for him was profoundly affecting for me.
Actually, he is me a so-called expert, and I felt like I was an expert by an experience. But the good news is that my we got there in the end and my dad had superb person centred care in the last four years of his life and good social care gave him his life back. So that's the good news.
But getting that, that's a different story. So that was that was the personal process that caused me to write the book.
And I think that's, you know, it's a very interesting point a bit that what navigating the system, because I think one of the many things that your book does well is as can capture and convey the complexity of the social care system on so many levels from funding to legalities and the organisation it. I'm conscious of your answer to my opening question about so much of what we hear about social care, focusing on the negatives on your unit to think maybe more positively and more, I guess proactively, but just want to you know, you obviously the title of your book is Ending the Social Care Crisis.
We know that that word is banded about a lot and a lot of people are quite critical of the use of that term crisis for you, What are the most what are the most urgent issues and social care in England?
I think if you asked many people that question, they would they would refer to things like the workforce. The fact that this over hundred 60,000 vacancies, the lack of money, austerity, the impact that's had, the impact of COVID, people stuck in hospital, in the market, in the care that they need, younger disabled people not getting choice and control, that sort of thing.
And those are all valid issues, but I think they are symptoms. And it seems to me that they the underlying cause of those symptoms is the failure to bring social care up to date. So the in response to the great sweep of change we've seen in this country over the last 75 years. I mean, interestingly, I think a lot of the problems in the NHS are caused by a failure to address the new realities of life as it is 75 years on from when it was in 1948.
And and I think the fundamental problem with social care is that we're still stuck in this 1948 mindset. The former minister once talked about social care as dirty little secret, which is that in fact it's not like the NHS is not universal. It's actually a very minimal safety net for the poorest people with the greatest needs. And that's become more accentuated in recent years.
And that is the fundamental operating model for social care that unless you're relatively poor and unless you have very high needs, you're on your own. Actually, there have been some attempts to kind of shift that over the years, that creation of Social services department in the seventies and that we have the community care reforms and the CARE Act has tried to make it a bit more universal, but I think it's tried it because of lack of investment.
So the basic trajectory of social care, which is a minimal safety net for a relatively small number of people, hasn't really changed very much. We still have means testing, for example, in a way that would be unthinkable if we applied that to the NHS. So we and because we're all better off or many of us are better off, that has become a live issue.
The issue of people having to sell their homes to today again, wasn't an issue in 1948. Most people didn't own homes. Most people didn't live long enough to meet a need for more care, and if they did, they didn't get it from their families or from the NHS. Know in a long stay ward or whatever. So we had all these changes over 75 years and we're still operating the tramlines for social care of a 1948 settlement.
That is the fundamental underlying cause of why we have got so many so many symptoms and pressures bubbling up.
Thank you very much. So there's so much in this book that is is very informative and nuanced that your point there about the sum of the differences between the social care and the NHS. You mentioned about the social care being means tested and you kind of pointed that out. You know, the idea of that and that being the case for the NHS is sort of unfathomable.
And one point quite early in the book you state that there's a different, a different political or moral calculus to entitlements for social care compared with health care. Can you say a little bit about that? Why? It's one of the things about social care that interests me a lot about I'm interested to think about and what about why that may be the case and why you think that may be the case?
Sure. So I think it's back to this issue of universality in part that that back in 1948, when it was all set up and the NHS was created to great fanfare, that wonderful leaflet that everybody pushed through the letterbox explaining what this new service was, that everybody could use it. It would be free at points of use, it would be paid for through taxes, and because at that point virtually everybody would need health care at some point in their lives.
This created a huge relief that was no longer the fear of a doctor or, you know, getting the health care you need. So so, you know, that that kind of began the country's long love affair with the NHS, which continues to this day despite the current travails. And the point is that the NHS gives people that a huge peace of mind, knowing that whatever happens to the health lies and worry about the bill.
Now, the same thinking, I think, wasn't applied to social care then. We didn't talk. Nobody talked about social care. In 1948. The opening words of the equivalent legislation, social care, which was the National Assistance Act, basically said not to eliminate the poor. So that was as good as it That was good as it got. And then, of course, life expectancy was much lower.
We didn't see the levels of chronic illness and disease that we have now. So the incidence of social kind of need in the general populace was very low and people just didn't see it as an issue. And it wasn't for reasons previously explained. And that that has persisted even though all these years later that the demographic position has fundamentally changed.
Most of us now will have some kind of kind of need at some point in our lives. We don't know when, we don't know for how long we might be end of life. It might be much earlier in our lives because of a disability road accident, injuries acquired in military service could be any reason or it is just personal misfortune.
So most of us will have a kind of need. One in seven of us will need care that costs at least £200,000. So this is this is a huge change since 1948. So I think we'll probably come onto this later. But I think the public as a whole generally don't appreciate the significance of it and the fact that social care is now as universal a need as as is health care.
That wasn't the case in 48, but we're still operating with this kind of twin trap, rather schizoid attitude that the NHS must be free at the point of view. Suarez Social care. Let's have a debate about how much people have got to pay and what carers have got to do. And you know, politicians can openly state that they think that a family should, should be the primary, should have primary responsibility for care and all sorts of statements which if they were applied to the NHS, would be greeted with outrage.
Can you imagine anybody having to sell a house, pay for their cancer treatment? You know? I mean, no other politician would get away with that. So I think we do need to expose this kind of almost hypocrisy, actually, not much, because need is need, whether it's health care need or it's for carers at all.
Yeah, And I think that that final point you make there about how often debate about funding and reform of social care seems to boil down to property and wealth and things like that. And I think that's a very important point. And how can we get beyond that? How do you think we can we can get beyond that discussion?
So I think the traditional approach to the social care reform is essentially consisted of various kind of reformers and lobbyists and campaigners, essentially shouting at the government to do something about social care, to demand that the government is something which the government of the day thinks will be poorly understood by the public, will be politically unpopular, will cost them votes and actually they've got they've got some cause to believe in that you look at what happened with so-called death tax, right in the 2010 election and then Theresa may had the same issue with her dementia tax debacle in the 2000 2017 election.
So it's very easy, particularly election time for politicians to kind of weaponise social care and use their opponents commitments as a as a kind of stick to beat them with. So so I think fundament one of the fundamental changes we've got to adopt is actually taking the arguments to the public and be very influenced by the work of an American political scientist, Joseph Overton, who said that instead of campaigners, policy makers, instead of trying to persuade politicians to do unpopular things, we've got to persuade the public to support popular policies.
You've got to get the policy in that Overton window where changes is is supportable. And so that's what I think we've got to do. We've got to raise public awareness that social care is a universal need. It's important for our peace of mind. It's important that that carers can go out to work, that disabled people can get jobs through the right social care support.
And we don't have to worry about it in some way, that we don't have to worry about health care costs. So that that means turning the policy, making process on its own and starting with the public.
Okay. Thank you. Thank you very much, Richard. And I was interested in your point and your opening answer about the idea of having a book in and having a lot of these important issues and ideas in one place. And I think the book acts as a know, as a great resource for that. And to that end, aims. So in chapter two of the book, you discuss the history of social care, adult social care in England, and you've obviously touched on quite a lot of some of these policy changes already, and you've also kind of linked that and with some of the kind of wider societal demographic changes.
I just wanted to ask if there's anything you think that we can learn from the sort of history, the historical trajectory that would help improve things today?
I think the most significant learning point is not to overestimate the impact of policy, the policy process. So, you know, in and when in the last, I don't know, 25 years we've seen a procession of white papers, green papers, consultation documents full of great ambitions and laudable intent. But in practice I haven't really made that much difference to the lives of people with social care needs.
So, I mean, there have been some improvements and some breakthroughs, but generally speaking, they have failed deliver reform at the scale that we need to to to meet all those challenges that have developed over the last 75 years. The second thing I think we can learn is, is is the importance of unintended consequences of things that happen that nobody planned or make explicit decisions.
And there are two things that I regard out in the in the book. One is about how we ended up with this huge private market whereby over 90% of social care services are provided by private and independent sector organisations. Nobody ever said, Let's have this big private market. It came about way back in the in the 1980s. And so really this relatively obscure decision of a local Social Security office is who decided, faced with pressure from local voluntary organisations and charities running residential services that Social Security should pay a board and lodging allowance for their residents because they were under the cosh financially and in one of two offices agreed that it became a national
policy. And that was the that was the blue light really for all sorts of people piling in and setting up care homes because they could get bulk of the cost paid for through Social Security without any assessment of need. And that marked the beginning of a rapid explosion in the number of private care places and the emergence of this vast state funded but privately run industry.
And that's why we have got the so-called market in social care that we have today. Governments tried to try to regulate that. They brought in the community care reforms. They cut Social Security budget, transferred it to councils, and expected them to assess people's needs for the first time and ration the care which they did very effectively. But of course there was the money transfer.
It wasn't enough and it wasn't enough to keep up with demographic demand and costs. And that helps to explain why so many councils have been struggling and why providers complain that councils are not paying them enough. So that's that's a little bit of history, which most people don't when a lot of people don't fully appreciate that it wasn't an explicit policy choice to do it that way.
The other developments, I think, which is enormously shaped the way social care operates today, is changes in the NHS. And what we've seen over the last 30 years or so is a massive offloading of both costs and activity from the NHS on social care. And although the debate currently is about the pressures that social care creates for the NHS, but actually it's it's two way traffic.
So the NHS has closed a lot of, of its long stay provision. I mean a lot of these developments are positive in the sense that nobody would oppose them. So they closed a lot of their long stay provision, they transferred some of that provision for mental health and then disability so that to the private sector they've reduced the number of acute hospital beds, which is now kind of coming back to two and they've reduced length of stay in hospitals and they do more treatments on a daily case basis.
But the effect of those little group of changes is to is to shift their recuperative to kind of the convalescent part of a person's hospital journey onto the onto the shoulders of families in the social care system. So people are discharged from hospital much sooner. That's usually that's a good thing. Nobody needs to be in hospital and unless they aren't, they are acutely unwell.
But again, that wasn't planned and nobody said, well, we're going to do this, but this is going to have an impact all on social care and on some community health services like district nurses, for example. Nobody said let's kind of plan to ship some resource across. It just happened. Not any planning, any sort of estimates of the resource requirements.
So that means that the volume of work, the amount, what the social care system has to do is much greater. But also I think it means that the acuity and the complexity of people's needs is much greater. And if you talk to anybody that's in home care services over the over the next few years and they will say now that they're dealing with needs that people have in their own homes, that previously district nurses would have done people in care homes would say that that that that a lot of their residents now years ago would have been in a in a nursing home.
And people in nursing homes would say a lot of their residents would have been in a hospice or in a hospital. But so there has been this big shift in acuity of need over a number of years. And that means that because of the resource constraints, fewer people are getting more care, they're getting more intensive care packages of care and support.
And it's also got big implications for the nature of the workforce. You need to deliver that at the skill levels, which is why these absolutely absurd to suggest a someday that such care is not a skilled occupation patently is not the case anymore. If you ever if it ever was. So those are those are the two of the biggest kind of factors we can only think of that we can learn from history about unintended consequences.
And don't overestimate what the latest Green Paper white paper is. It's not going to change the world publicly.
Thank you very much. And in terms of thinking about another context or moving from the historical context to the I guess, to the geographic of the political context in chapter five, if you look abroad. And so can you can you briefly see what we could learn from other countries? Maybe give an example?
Yeah. So I spent a lot of time actually looking at other countries and, you know, there's different approaches. And I think the one obvious learning point is that there is no magic bullet here that we that we you could say, well, if, if we do, Australia did or what we have done, everything will be okay. And so there is no one set of solutions that can easily be replicated in another country because it's all very context specific.
Every country's got its own unique context and culture which shapes the way it does things. And I think this stories call it path dependency so that when Germany, for example, was reforming its its approach to social care, it adopted a long term care insurance doctor. It went down a social insurance. Right. And that's because there is a long tradition in Germany, particularly through health care of social insurance.
It began with Bismarck in the 19th century with unemployment insurance. So Germany went down that road. Scandinavians have opted more for general taxation as a as a as a as a funding method. So every country is different in that sense. But I think I think on a positive note, I mean, we can take hope from the fact that many countries have introduced long term reforms, you know, a whole range of countries across the world have done this.
I don't think anybody has really cracked the problem. It's a bit like painting the fourth bridge. So what most countries tend to find is they introduce changes to make that care better. And whenever you do that as a learning point, the costs go up because more people come forward and needs help rebuild. So there's that debate about, well, how do we make this sustainable?
And then they are just as they go along. So even countries with social insurance schemes find that they have to look at kind of subsidising it with money from general taxation countries, even countries like Sweden or Netherlands, Scandinavian countries generally rely on some personal payments to top up relatively high levels of state expenditure. So so I think the lesson is that you can do this.
It is possible to introduce change, but you then have to kind of adjust it as you go along and not expect, not expect it to kind of improve things all at once. And that's the third point actually. It takes time. And if you look at if you look at Japan and Germany, which is to the examples that are often quoted, I mean, they took over a decade to kind of launch the process to get people on board, raise awareness of the issues.
And it was not that methodical, planned approach, preparing around instead of doing what we've tended to do over the years, which is plunge straight into let's have a levy on people's estates to pay for social care, never mind starting with engaging with the public about what is social care, why is this important? How much does it cost?
These are some of the ways we could pay for it. What do you think we go straight in with? You know, let's have this new tax to pay for social care, which immediately frightens the horses and talks. You finance the whole issue. So I think there's a lot we can learn from other countries about the process. I've been particularly impressed in in the United States with the came across Generations movement, which is a very broad alliance campaigning groups trying to get improved care and support for carers of all ages and both for children and for adults and for younger disabled people who I think have had some success in creating public support for change.
That what I talked about earlier, that the public realisation good care is something we need to live our lives, to live a good, a good, a good life. So there's lots of movements like that I think we can learn from in Australia and I have every Australian counts. We're in some really, really good work on breaking beyond, breaking out of the shackles of the traditional policymaking process whereby the government issues a Green paper, the statutory consultation period.
You have to write here, this is much more fresh and much more engaging.
Thanks very much, Richard. That's really interesting how these insights from different, different places. So as you said in your opening answer, you know, one of the things you're trying to think about is that big question or what can we do? And so you save your most deepest and most developed ideas for reform through the final chapter of your book.
But yeah, you make suggestions and recommendations throughout the book. Maybe for the potential readers, can you maybe briefly summarise some of your kind of key proposals for reforms or some of the key things that you think it would make a difference?
So first of all, I think it's it's important to distinguish between process and outcomes. I think a lot of the debate in England has been quite technical. It's been about policy options, funding methods and so on, and it's been quite, quite narrow and we haven't really thought very much about the process of change. You can have all these wonderful ideas, but how do you actually get them and implement it?
So, so I think this is three, I call it a different road to reform. And there's three things that have got to be fundamentally different. So the first is, is a is a new focus on building public support for better social care. And I talked about that earlier, so I won't repeat it, but it's just kind of making people aware that the social care is really, really important for us to have a good life, to enjoy the peace of mind that we have with healthcare through the NHS.
So so, you know, I think we need a whole load of public conversations, probably locally, then builds up into a to a national debate and dialogue and to get social care into the Overton window of, of of realistic change. Second thing we've got to do different and it's it's part of the process of building public support is to really get into some of the tools and techniques of deliberative democracy and co-production of involving people with lived experience in social care, much more of engaging with local groups and citizens about this.
There was some some recent examples of focus groups of citizen assemblies and so on, participatory budgeting to to really get alongside people and work up some ideas and then get people on board the issues that need to be tackled. The third thing I think we've got to do is, is to shift from short term fixes, which I think has been a real problem to social capital in the last 7 to 10 years that government has actually put more money in, but it's done it in the least effective, efficient way is short term last minute hand-to-mouth funding.
That's all going to be spent within months. And, you know, and actually it almost perpetuates a broken system. It it props it up. Instead of building a bridge to a better system, those kind of short term bulks of money just prop up a failing system and and and everybody that works in such got no that the problems are not going to be fixed overnight they're going to they're going to need a long term approach.
So so a shift from short term fixes to long term planning. So those are the three process things which I think need to be different in terms of policy ideas. I mean, I could talk for England on this in terms of the outcomes that we want, but it seems to me there are some really three big things we should be looking to achieve.
The first is a new social contract for care, a new kind of deal that really clarifies and sets out what people can reasonably expect from the state in terms of not only care delivery, but who pays for it as well. But but also people's sense of obligation and responsive abilities that we have towards each other. And I've been very influenced by New Shafiq's book on the new new social contract.
What we are each other, because as I said earlier, we're still operating in tramlines of a 1948 social contract when the expectation was actually that in return for family allowances for free education, universal health care and full employment, that basically women would stay at home and look after the kids and and relatives needing cash but never written down.
But that was basically the deal. And of course that's gone now, totally unsustainable and inequitable, but we don't have anything to replace it. So I think we do need to. A new social contract that also would make social got much more intelligible and easier to understand and navigate. The second big change I think we need to look towards is really turning upside down the very traditional model of care that we have at the moment, which is very much based on professional discretion and eligibility and what's around in your area.
And I think we need to shift the balance fundamentally towards giving people the opportunity to direct parents support, not just through relatively crude mechanisms like personal budgets, but actually giving them rights that can be enforced when they can't get their direct payments or whatever. And really make it possible for individuals to shape their own care and support and try and recapture some of the promise of the direct payments movement so that 30 years ago.
And the third outcome, I think this is the final one and it's crucial and that is a new funding settlement, a new poll, probably part of the new social contract about what is reasonable to expect from private contributors as opposed to the public purse. And that might be anything from free, completely free personal care towards, you know, modest contributions for the accommodation costs or whatever.
That's where we need to have the debates, I think. But as I emphasised earlier, we need to that needs to come at the end when we're clear about what is social care that we need and what is it we're trying to fund in the first place. But we can't we can't fudge that. And in the book I talk about all sorts of ways that we can raise money.
These are essentially political choices. I personally feel that where social care suffers at the moment is that our tax system in England is heavily skewed towards taxes on work rather than taxes on wealth. And actually we have vast sums of property wealth, in particular in pension wealth. Much of it is unearned. And we ought to be thinking much more imaginatively about how we broaden the base of that up.
That perhaps gets us into a different, different kind of discussion. But the point is that social care is affordable. You know, it's about our relative priorities. And I think if we were stuck and went back to 1948, knowing then what we know now, we wouldn't end up with 170 billion. And in just budget and a 22 billion in social care, but it would probably be much more equally balanced.
Thank you very much. And I think that I am gives a great kind of introduction to to the those points that obviously in the book you develop those a lot more and I'd certainly recommend to people to go and engage with those more in the book. So just finally, I just wanted to ask you about the, I guess, the life of the book or what your you know, you talked in the style.
Some of your motivations and the idea of having your ideas in one place, the experience, your personal experience with your, with your father, even the opportunity, I guess a little bit and you had through, through lockdown in that time. But what were your hopes for the book?
Yes, I mean, the interesting I decided to write from the word go that I wasn't going to write a traditional textbook. I wanted this to be of interest and relevance to a wide range of people, kind of reassured by comments from friends and relatives that actually they thought they thought it was much more readable than they thought it was going to be.
I'll take Grace wherever it comes from, really. So it was yeah, it was aimed to be accessible. So, you know, I hope that it will be read by a wide range of people. I suspect at the moment that it's I'm preaching to the converted, to be honest. In terms of current readership. And, you know, I'm not I'm not sure how you how you break out of that.
But you know I just wanted to kind of, you know, just help stimulate the debate there, really. And I think one of the problems with the social sector, if I can use that term, is that it tends to be same people having the same conversations with each other. And I do feel that we've got to get the great strength of social care and the enormous potential it has to as a force of good in society, that we need to get that out there in the wider public so that people can realise just how important this is and what a great thing it is, that it's something that's that is worthy of investigating, whether that's through our taxes or whatever other resources.
All that said, thanks very much for that, Richard. And can I just ask you, can you just share with listeners how they can get a hold of the book?
Well, gosh, yeah. So, I mean, I think you can you can get it through. You can get it through Amazon, obviously, and other online sellers. You can order it directly from the policy press at the University of Bristol.
Thank you. For more episodes in the Care Matters series and to learn more about the Centre for Care, please follow the link in the episode description for a website and social media channels. All that remains for me to do is to thank our guest, Richard Humphries. So thank you very much, Richard.
Thank you.
Thank you for listening. Thank you.