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19 Feb 2021


The year 2020 will stand out as an ‘annus horribilis’ in social care. Not only did Covid-19 sweep through care homes killing many older people, it killed other disabled people receiving care at home, and many working in social care.

Such a perfect storm would destabilise any sector, but social care in England was already precarious. Huge workforce vacancies, high staff turnover, limited technology, lack of NHS support, inabilities to operate profitably or to break even, and fragmentation, have long haunted this largely privately-provided sector.

Promises to reform adult social care were wearing thin (after all there have been 17 social care funding reform white and green papers, and official reviews since the millennium), with a chorus of concern from pressure groups, commentators and politicians that ‘something’ needed to be done.

A few ‘sticking plaster’ efforts (e.g. the Better Care Fund) have added some extra money here and there, but less than needed to compensate for austerity, growing demand, population growth and survival, minimum wage rises, and NHS concentrations on acute care.

Older people and carers are now reporting ‘excess’ disability from limited social activity and contact (meaning that needs are further increasing). Even before Covid-19 the sector was frequently described as being in crisis or at the point of market failure.

Where are we now?

We have been living in the land of promises to ‘fix’ social care (the latest in the 2020 Treasury Spending Review). Talk of a policy ‘window’ from Covid-19, meaning that things might be done opportunistically, could seem cynical but may provide the final stimulus.

In social care, Brexit-related debate centres around immigration. EU workers have helped sustain the sector over recent years, particularly in London and the South. In preparation for Brexit, the UK adopted a points-based immigration system on 1 January 2021 but made no exemptions for frontline social care jobs.

This is despite the sector (in the form of the Cavendish Coalition and others) arguing that occupations which provide a ‘high public value’ should include low paid care workers.

Whether unemployment in other sectors following the pandemic will compensate for fewer EU workers is unknown. The sector has been reporting greater interest in its jobs —although this is not always translating into footfall.

Further optimism comes from increasing applications for nursing programmes which may signal greater interest in doing work that is worthwhile, but the better terms and conditions offered by the NHS will be far more attractive than social care, where wages are often lower than those paid by supermarkets.

Where are we heading?

The roll-out of coronavirus vaccines is helping the care sector to sustain its provision and morale with an expert prediction that care home occupancy will be back to pre-Covid-19 levels at the end of 2021.

Confidence in care may increase, so helping this part of the sector to balance its books by filling places and holding on to staff.

The sector, previously often seen as uncaring, may also have acquired an improved image. Politicians may have the time, commitment, and courage to deliver on the promised reforms of social care, seeing Covid-19 as opening that policy window.

In the myriad reports about social care, there is general consensus that the key decisions are about money: the pot (size of),the purse (who will pay),the timing (‘pay as you go’ or use care,or mortgaging the future, aka getting the kids to pay), the rules (competition and/or subsidy) and how (splitting responsibility between individuals and taxation).

All this means not just one decision but several. Just two illustrate their complexity. First, the care sector gets buffeted by other parts of the public sector,especially from pressures inside the NHS that affect what gets defined as ‘care’.

Living up to the promises in the Care Act 2014 that local councils should play a part in ‘shaping the local care market’ would be easier if NHS funding could be used. Post-Covid-19 movement of NHS funds may not be so feasible as little might be left in NHS coffers.

Second, agreeing a ‘cap’ (a limit on the cumulative amount people have to pay for care before the state picks up the cost) to assuage property owners’ or inheritors’ fears of ‘catastrophic costs’ (whereby savings are depleted) may be popular in many circles.

But it is not progressive and won’t add extra money. Setting a ‘cap’ is likely, but there will be a real risk of over-promising and so disappointment.

There seems little appetite for individual private insurance schemes unless they are secure and credible. A more radical approach may now be more acceptable; whether this is a form of national insurance, taxation, reallocation of some social security awards, extending co-payment, further managing the market or renegotiating ‘free’ entitlements, in combination or in part.

Winners certainly, but losers too. And does any of that sound simple?

Such proposals often have care homes in mind. But why not shift from care homes to address care at home? It is here that most people with needs for care live and want to stay.

And care at home is also provided by family members — often at great personal and financial cost — so their voices need to be heard. Policy makers and the public also tend to forget that much publicly funded social care is for younger disabled adults; and ideas of insurance and co-payments are less viable here.

Many of them are employers of their own care workers, complicating further the care labour market, and have a lot to say about their lives and how good support matters. As indeed it does or will to us all.


The views expressed in this publication are those of the author and not necessarily those of the National Institute for Health Research (NIHR), the NHS, or the Department of Health and Social Care.

By Professor Jill Manthorpe, Professor of Social Work at King’s College London and Director of the NIHR Health & Social Care Workforce Research Unit. This piece was taken from the Brexit and Beyond: Policy report.


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