Intended for healthcare professionals

Opinion Acute Perspective

David Oliver: England is still waiting for social care solutions

BMJ 2022; 379 doi: (Published 30 November 2022) Cite this as: BMJ 2022;379:o2861
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter @mancunianmedic

In Samuel Beckett’s Waiting for Godot, Vladimir says, “Well. What do we do?”—to which Estragon replies, “Don’t let’s do anything. It’s safer.” Later, Estragon tells us that “nothing happens. Nobody comes. Nobody goes. It’s awful.”1

Waiting for meaningful solutions in social care policy feels very similar, with little hope on the horizon. A quick historical timeline serves to emphasise the despair many of us feel, as keenly as Beckett’s protagonists.

The Sutherland royal commission’s With Respect to Old Age report, published in 1999, made a series of recommendations on adult social care funding and provision,2 with few fully implemented. In 2010 the health secretary, Andy Burnham, tried to convene cross party talks on sustainable solutions, which were boycotted by the Conservatives and briefed against as a “death tax.”3 In 2011 the government commission chaired by Andrew Dilnot took extensive evidence, examined several options, and recommended a lifetime cap on care costs and a more generous means test.45 But after the 2015 general election the Conservatives reneged on the coalition pledge to enact it.6

The well regarded Care Act 2014 set out a range of rights and responsibilities around care and support,7 which have never been accompanied by the resources or staffing to make good on the intentions. That same year a King’s Fund commission chaired by Kate Barker, economist and former member of the Bank of England’s Monetary Policy Committee, also set out a series of recommendations on funding and access that weren’t heeded by politicians.8

Heavily rationed

Meanwhile, austerity policy under the 2010-15 coalition government and in the following parliament led to sustained cuts in local government budgets (and hence social care).9 The King’s Fund and the Nuffield Trust estimated in 2016 that 500 000 fewer people were in receipt of care by the middle of the last decade than at the start.10 Annual surveys by Carers UK show that most care is delivered unpaid by family members and that they, in turn, receive little statutory support.11

Yes, there have been a series of in-year cash injections to social care, largely focused around supporting discharge from hospital and joint working between the NHS and social care, but they’ve never compensated for the cuts.12 In 2021, modelling by the Health Foundation suggested that by 2030 adult social care in England would need an annual uplift of £8.9bn (€10.3bn; $10.7bn) just to maintain current levels of service and £14.4bn to restore access to historic levels.13 Social care access is already heavily rationed by strict eligibility thresholds and means testing.14

During the 2017 general election campaign Theresa May, then prime minister, announced rather hastily a proposal to fund care from recipients’ estates, which was soon decried as a “dementia tax” and dropped.15 Then, right after his 2019 election victory, Boris Johnson pledged to “fix the crisis in social care, once and for all with a plan.”16 The Queen’s speech, 657 days later, lacked any meaningful commitments to back this up.17

When the “solution” was finally announced in 2021, it was no such thing. An additional £33bn over three years was to be raised by a “levy” in the form of national insurance increases on working adults. But most of the cash was to be given to the NHS, leaving only £1.7bn a year to social care—most of which would be swallowed up in protecting people whose assets exceeded the £86 000 cap from using all of them.18

The national insurance rise (now reversed by the current leadership) was criticised from both right and left for being inequitable, placing an excessive burden on one part of the adult population (not those receiving care), and for being regressive in that lower earners paid a higher proportion of their income as a flat national insurance rate.19 The health and social care secretary in the six week Truss government of 2022 was gone before she could offer a serious proposal of her own, beyond a short term winter cash injection of £530m—which has yet to be released to the system and focused entirely on supporting hospital discharge.20

Meanwhile, one in nine social care posts is vacant in a worsening workforce crisis,21 as the sector deals with poor funding, falling profit margins, points based immigration rules, the impact of Brexit, and competing sectors also short of labour.2122 In his autumn statement the chancellor, Jeremy Hunt, unexpectedly announced an extra £7.5 bn for social care over the next two years.23 But nearly half of this will come from postponing the new cap and other funding reforms, while almost a quarter will depend on all councils choosing to raise their council tax.24 Even assuming that every local authority employs this option, it’s no panacea. Much will depend on the local government financial settlement to be announced later.

Wages and energy costs

Local authorities rely heavily on central government grants for funding. These grants have been serially cut, and the Institute for Government found that cuts have hit deprived areas harder.25 Moreover, council tax is regressive and compounds the inverse care law: areas with the highest value properties and the highest proportions of homeowners (and the lowest need to provide public or subsidised housing) are the areas that can raise the most money, even though they’re less deprived.26

In any case, it’s likely that much of the new money will be sucked into wage increases and energy costs rather than widening or preserving access to adult social care.27 And neither Hunt nor Steve Barclay, the new health secretary, has presented any meaningful solution to social care’s recruitment and retention crisis. With no workforce there can be no care, even if the money’s there.

Vladimir and Estragon—living in a dystopian no man’s land removed from reality, while the real world continues elsewhere—would recognise this exercise in futility. But their predicament lasts for only two hours (with an interval), not two decades.