“My job is to protect you or your parents or grandparents from the fear of having to sell your home to pay for the costs of care and so I am announcing now – on the steps of Downing Street – that we will fix the crisis in social care once and for all with a clear plan we have prepared to give every older person the dignity and security they deserve.”
Boris Johnson [1]
Boris Johnson’s commitment to ‘fix the crisis in social care’ should be good news, and welcomed as a sign of long-overdue action by the government, so why do the words he used in his first speech as Prime Minister make me go hmmm?
In this blog I’ll explore how the language and tone of his announcement echoes much of what is wrong with the current social care system he’s so keen to fix, and how each part of his narrow-focused, deficit-based, top-down pledge completely contradicts the positive, innovative and collaborative approaches of those of us who are working to radically change the system and build a better, brighter social care future.
“My job is to protect…”
In his promise to ‘protect’, the new Prime Minister is echoing the paternalistic approach that social care needs to move away from. He is taking charge, exerting his authority from ‘the steps of Downing Street’ and ‘doing-to’ us, the public. But we know that this top-down approach is out-dated. Most of us don’t want to be passive recipients, told what to do by people far removed from our everyday lives. We don’t want to work in a system governed from afar by people with no sense of what really happens, or matters, on the ground. And even if we were happy to relinquish all responsibility for decisions about our lives, we know that this command and control approach is no-longer sustainable. It creates too much distance, removes decision-making power from those who need it most, spreads resentment and distrust, and crushes initiative and innovation.
Social care works in our better, brighter future because responsibility and decisions are shared. We listen to, trust and respect each other. We recognise that we are all experts in our own lives, with our own ideas about what makes our lives good, and we know that if we work together, we’re more likely to realise our ambitions.
“… you or your parents or grandparents…”
In his statement, Boris Johnson mentions ‘you or your parents or grandparents’, and later ‘every older person’. But what about the people of working age who are just as likely to rely on social care support, including all those currently excluded by eligibility determinations and means-tests? What about the millions of unpaid family members, friends and neighbours sustaining the current system? What about the hardworking social care workforce who are increasingly disillusioned by demands from the top, and distanced from those they are employed to support?
All too often in our rush to assess, we narrow our focus to ‘presenting needs’ and fail to see the whole person in the context of their life. If the new Prime Minister really intends to focus only on social care for older people, he will fail to see the bigger picture, and he will fail to make much difference at all.
“… from the fear of having to sell your home to pay for the costs of care…”
The focus on selling homes to pay for the costs of care is also, as Sally Warren, Director of Policy at The King’s Fund, points out, “an extremely narrow frame of reference.” [2] It further limits the conversation, not just to older people, but to those older people who have assets to sell. And it also suggests that moving into a care home is the only option. While it’s true that residential care remains the default solution for many older people in the current world of social care, it is far from the only option, and there is an increasing focus on supporting people of all ages to live healthy, independent and connected lives in their own homes rather than relying on formal services and institutionalised care. Indeed, the Equality and Human Rights Commission (EHRC) has called for disabled and older people to have the legal right to homes in the community rather than being forced to live in institutions. [3]
No one would deny we need to talk about money. There is a desperate need for a hefty injection of cash into a sector starved of funds. The findings of the most recent ADASS budget survey revealed that “since the beginning of the decade, adult social care directors in councils across England have had to make a staggering £7 billion of savings, and need to find a further £700 million for 2019/20.” [4] And last year, analysis by The King’s Fund suggested that simply maintaining the system at 2015/16 levels would require an extra £1.5 billion in 2020/21, rising to £6 billion by 2030/31, while to return to the level of quality and access observed in 2009/10, and meet demand pressures since then, would require much greater levels of investment: £8 billion in 2020/21, and £15 billion in 2030/31. [5]
However, money alone is far from the solution to our broken social care system, which is crying out for much more radical change. In the new world, by focusing on what matters to people, working collaboratively with them, their networks and our networks to achieve good lives, talking rather than arguing, and reducing bureaucratic processes, often we find that costs are significantly reduced. Indeed evidence from Wigan [6], Worcestershire [7] and Thurrock [8] shows that significant savings can be achieved by “doing the right thing”.
And finally, to mention fear plays to the sensationalist framing of adult social care (more on that later).
“…and so I am announcing now – on the steps of Downing Street – …”
The reference to Downing Street reminds us of the power dynamic and the politics at play here. Successive governments have failed to ‘fix social care’ because it’s not a vote winning strategy. Promises of more money for the NHS wins votes (think buses and Brexit) but because so little is known or understood about social care and in particular how it is funded, any political discussion about paying for care – particularly if the solution includes tax increases – is unlikely to land well in the media or with voters (remember the Conservatives’ ‘Dementia tax’ and Labour’s ‘Death tax’?).
In our current social care world, many decisions are ultimately made by senior managers removed from the reality of individual’s lives, and often motivated by the wrong reasons i.e. cost [9]. Any government’s decisions are inevitably politically motivated (and Boris Johnson’s focus on protecting the housing assets of older people is undoubtedly an attempt to pacify his core voters) – so if we’re going to have a genuine, honest discussion about the future of social care it needs to take place away from the steps of Downing Street and beyond the boundaries of Westminster, and be led not by politicians motivated by their political careers but by people who genuinely care about each other and about building a better social care future for everyone.
“…we will fix the crisis in social care once and for all…”
The media, charities and social care commentators delight in using dramatic language to describe social care. Headlines scream of ‘crisis’, ‘scandal’, ‘car-crash’ and ‘disaster’.
Frame social care as a crisis, and you get a crisis response. It’s the same response many of us employ every day in the statutory social care world: focusing on what’s wrong; assessing the situation through a narrow lens; making assumptions about problems and needs, responding with our standard set of service solutions and moving on.
As we know all too well, assessing people and fixing them with services ensures they survive, but doesn’t support them to thrive. Our ‘old world’ crisis response may meet presenting needs, but it doesn’t develop capabilities, encourage shared responsibilities, or create new opportunities. And by focusing on individuals, it often misses relationships out of the picture entirely. As such, people come back again and again because our plans for their lives turned out to be sticking plasters – a short term cure rather than a longer-term, sustainable solution.
Advocates of a different social care world describe the need to separate out our crisis response from conversations about longer term support. Alex Fox writes of “two possible kinds of offer for anyone approaching a support service: immediate crisis support for those who appeared to need it, or the help, advice and information needed to draft a ‘wellbeing and resilience plan’.” [10] And one of the main rules of the Partners4Change Three Conversations® approach [11] is to never plan long-term in a crisis, but instead to work intensively with people to help them regain some stability and control in their lives before moving on to talk about longer-term support.
If the government were to adopt a similar approach, it would have two options. Continue to frame social care as a crisis and respond with a short-term plan to provide some stability, but with little long -term impact on people’s lives, as any extra funding will be quickly swallowed up in maintaining the bureaucracy of the current system. Or, move away from the crisis framing and instead start by telling a different story about social care. Highlight the positives, embrace the opportunities, and develop a long-term ‘wellbeing and resilience plan’ for the social care future.
“…with a clear plan we have prepared…”
A clear plan for social care has been elusive for a long time, with the green paper promised over two years ago postposed a staggering six times. In his speech, the new Prime Minister gave no detail about what his plan is. However, reports suggest that it will be in the form of a white paper, not a green one, and there is much speculation about whether the plan will include the voluntary insurance scheme favoured by Health and Social Care Secretary Matt Hancock.[12] [13]
The green paper had been so eagerly anticipated, not just for sight of the proposals it would contain, but also because its publication would provoke a national conversation about the future of social care. If the rumours are true that the paper is to be white rather than green, that opportunity for discussion and debate is removed. And if the plan does include a voluntary insurance scheme it seems doomed to fail, with Sir Andrew Dilnot calling the model “hopeless” [14] and Lord Michael Forsyth clear that a private scheme will not work. [15]
Whatever it contains, the preparation of a ‘clear plan’ with no prior conversation glaringly contradicts new ways of working in social care, where plans are made collaboratively – with the people who they directly affect taking a lead role and being fully involved in all decisions. Listening hard and building on what works are key, and connections and relationships play a vital role. Whether it’s a long-term plan for an individual’s ‘good life’, a changing approach in a workplace, or the development of new support in a community – we know that unless the right people are directly involved in decisions from the start, the plan is unlikely to succeed.
“…to give every older person the dignity and security they deserve…”
Again (sigh!), social care is not just about older people.
No one would deny that everyone deserves dignity and security. Sadly, all too often in the current adult social care world, dignity is a concept contained in principles and value statements and celebrated with awards, rather than embedded as fundamental at all levels. And security is often achieved and maintained by the risk assessments, restrictions and denied opportunities of traditional services and dehumanising institutions.
The focus of the future social care world is on living good lives, rather than just meeting basic, personal care needs and keeping people safe. Ordinary lives, lived “in the place we call home with the people we love, in communities where we look out for one another, doing the things that matter to us.” [16]
Rewriting Boris’s pledge
There is no question that many aspects of the current social care system are broken. It is failing financially and failing many of the people who depend on it, not to mention those excluded from it and those working (paid and unpaid) within it. However, the new Prime Minister’s pledge suggests that he aims to fix social care in the same way that social care aims to fix people – by assuming the role of the expert and focusing on problems. And we know that fixing people doesn’t work. If we only look at what’s wrong, we ignore what’s strong. If we focus on what the matter is, we miss what really matters.
If Boris Johnson continues to frame social care as a crisis, his solution will be an ‘old world’ crisis response. He’ll impose knee-jerk policies then walk away: quick-fix solutions to pacify his core voters and enable him to return his focus to ‘delivering Brexit’. But solutions imposed rather than agreed often do more harm than good, and as such his crisis response seems destined to fail [17] [18].
Instead, if the Prime Minister is serious about ‘fixing social care’, his promises should mirror the strengths-based approach of those leading the way in building a better, brighter social care future. Rather than completing a narrow assessment of what’s wrong, he needs to have an open, honest conversation with the people at the heart of the sector he’s attempting to save, to really understand what matters and what good looks like. Instead of focusing on problems, he should recognise and celebrate the innovative solutions already working well – the small-scale approaches that are making a huge difference [19]. And instead of recommending funding options which don’t add up, and wasting our money maintaining broken, dehumanising institutions, he should agree a sustainable, fair, funding solution and invest in support that builds relationships and communities and hope for us all.
Rather than a top-down solution, we need a cross-party, collaborative, long-term plan for social care, that everyone agrees on and signs up to. A plan that removes the barriers and bureaucracies of our existing system and supports and enables people of all ages, in their homes and their families and their communities and their workplaces, to work together to make their own long-term plans for living and supporting good, ordinary lives.
References
[1] Boris Johnson’s first speech as Prime Minister: 24 July 2019
[2] Social care funding reform: more haste, less speed Sally Warren, The King’s Fund, 31 July 2019
[3] Give older people legal right to live in their own homes Jamie Doward, The Observer, 4 August 2019
[4] Press release: ADASS budget survey: human cost of failing to address the crisis in adult social care Association of Directors of Adult Social Services (ADASS), 26 June 2019
[5] A fork in the road: next steps for social care funding reform Simon Bottery et al. The King’s Fund, 16 May 2018
[6] A citizen-led approach to health and care: Lessons from the Wigan Deal Chris Naylor and Dan Wellings, The King’s Fund, 26 June 2019
[7] New approach to Adult Social Care is helping people hold on to their independence Worcestershire County Council, 20 March 2019
[8] Glimpses of the future: The power of enterprising communities Sian Lockwood and Susie Finlayson, Social Care Future blog, 22 February 2019
[9] The funding panel policies testing the limits of the Care Act Rachel Carter, Community Care, 26 September 2018
[10] A new health and care system, Alex Fox, 2018
[11] The Three Conversations® Partners4Change
[12] Boris Johnson set to pledge billions for new hospitals and social care Sarah Neville, George Parker and Delphine Strauss, Financial Times, 30 July 2019
[13] What are Boris Johnson’s plans for adult social care? Sarah Clarke, Home Care Insight, 24 July 2019
[14] Social care insurance scheme would be “hopeless”, says Sir Andrew Dilnot Sarah Clarke, Home Care Insight, 6 August 2019
[15] Lord Forsyth: ‘Private insurance won’t fix the social care crisis’ Patrick Butler, Guardian, 30 July 2019
[16] Our story? Social care future blog, 19 June 2019
[17] Social care funding reform: more haste, less speed Sally Warren, The King’s Fund, 31 July 2019
[18] If the rumours are true, Boris’s social care plan is so bad he’d be better off not having one at all Harry Quilter-Pinner, Independent, 26 July 2019
[19] Including those described in Think Local Act Personal’s Directory of Innovations in Community Centred Support and in the Social Care Future blogs.
Rewriting social care 