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A New Road to Reform

What lies behind England’s crisis in adult social care, why has real change been so hard and what can be done?

Ensuring effective, sustainable and affordable care and support for people of all ages is an urgent public policy challenge. This vital book outlines a different vision of social care as an essential part of the country’s economic and social infrastructure that enables people to live good lives.

Drawing on the history of social care, international comparisons and lived experience, it sets out a different road to reform that will secure political traction and public support for change.

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This chapter sets out the reasons why social care has become such an important issue as a result of social and economic changes since 1948. It offers an overview of the key problems, challenges and issues; explains why the book was written; and concludes with an explanation of the structure of the book and a high-level summary of each chapter.

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This chapter contains a short history of social care since 1948: its origins in the Victorian Poor Law; the omission of social care in the 1948 welfare state settlement; the dramatic changes in the nature and volume of needs since the end of the Second World War; improvements in life expectancy; the impact of changes in health care and the withdrawal of the NHS from long-term care; the implications of the growth in property ownership and personal wealth; the key social policy and organisational developments, including the Seebohm and Community Care reorganisations; funding changes; and the outsourcing of services.

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The chapter examines how social care is defined and understood. It summarises the number of people who use social care, with numbers broken down by age and needs, including the primary reason why support is given. It describes how the system is supposed to work, including financial means testing and assessment of eligible needs to determine entitlement to help. How social care is funded through different national and local funding streams is summarised. The chapter highlights the impact of social care charges on individuals with care needs, and describes the difficulties of people with lived experience in navigating complex rules and systems. The financial resources involved, public and private, are set out, along with the importance of other separate, streams of public money aimed at care needs, described as ‘the social care pound’. The parallel system of self-funders who pay for their own care outside the public system is discussed.

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This chapter discusses the workforce aspects of the crisis in adult social care: both paid workers and people who provide unpaid care, noting that social care contributes to gender inequalities in society. The nuanced nature of care work is described, including the importance of relationships between carers and cared for in shaping outcomes and the quality of care. The composition of the paid workforce is summarised, underlining the low numbers in social care professions and the challenges of recruitment, retention and low pay. It discusses the impact of Brexit and immigration policy alongside future workforce needs, in terms of the numbers of people and the higher skill levels required for more complex and acute needs. The chapter laments the absence of a workforce strategy and sets out some short- and longer-term measures to tackle the immediate crises and secure a valued, well-trained and well-paid workforce for the future.

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This chapter argues that a different road to reform is needed to secure political traction and public support. It considers that the experience of COVID-19 is unlikely to create the conditions for a ‘Beveridge’ moment to trigger lasting reform to social care, akin to the new welfare state in the 1940s. Instead, a fundamentally different approach is needed to the politics and processes of change, with four dimensions: a clear framing of the purpose of social care, setting out the full range of problems and challenges; agreeing key design principles for a better social care system; establishing a bottom-up, citizen-led and co-produced approach to policy-making, nurturing cross-party cooperation and using participatory democracy and the power of social movements to nurture public support; and adopting a temporal shift from short-term fixes to long-term approaches, such as cathedral thinking, so we can become ‘good ancestors’ when it comes to social care.

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The final chapter examines the ‘Build Back Better’ plans for social care, concluding that bigger and more ambitious changes are needed. It sets out three building blocks of a new system, rooted in the belief that all advanced countries depend on good social care as part of their universal economic and social infrastructure, in the same way that they depend on education, skills and health care. They are: a new ‘social contract for care’ that sets out the mutual roles and responsibilities of individuals, families, communities and the state; a different model of design and delivery that gives people new rights and resources to shape their care and support arrangements, offers peace of mind, and secures a new deal for unpaid carers; a new funding settlement that positions social care as a major public service, on a par with other universal services such as education and health care.

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This chapter examines the efforts of successive governments to reform social care. It summarises the timeline of various inquiries, commissions and White Papers, including Dilnot; the ‘death tax’ row in 2010; the false dawn of the Care Act 2014; and the ‘dementia tax’ controversy in 2017. It refers to the ‘Build Back Better’ plans to introduce a cap on care costs and the White Paper ‘People at the Heart of Care’ published in 2021 (assessed more fully in ).

The chapter identifies what can be learned from failures in funding reform and what needs to be different for reform to succeed. This includes clarity in framing the purpose of reform; the importance of timing in relation to the electoral cycle; the need for cross-party cooperation if not consensus; raising public awareness of social care; and the need for realism in not making the perfect the enemy of the good.

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This chapter looks at the experience of other advanced countries who have introduced major reforms to long-term care (LTC) funding, and draws out lessons that can be learned and applied to England. The arrangements in continental Europe, Scandinavia, Japan and Australia are discussed, in terms of how they work and how they were introduced, including the role of mandatory social insurance schemes in some countries. UK expenditure on LTC is compared with that in other OECD countries, subject to caveats about differences in definitions and data collection. The implications for England are identified and discussed. The chapter concludes by assessing pointers from international evidence about the very limited potential of private insurance as a funding solution.

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